Inspection on 26/02/07 for Whitehall Lodge Residential Care Home

This inspection was carried out on 26th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Whitehall Lodge Residential Care... 24/03/09

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Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Whitehall Lodge Residential Care Home 56/112 Whitehall Road Norwich Norfolk NR2 3EW Lead Inspector Mrs Dorothy Binns Unannounced Inspection 26th February 2007 09:30 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 Whitehall Lodge Residential Care Home DS0000069104.V331676.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. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitehall Lodge Residential Care Home Address 56/112 Whitehall Road Norwich Norfolk NR2 3EW 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) 01603 618332 01603 766506 Whitehall Care Ltd Mrs Frances Sweatman Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: Whitehall Lodge is a registered care home for older people accommodating up to 29 service users. The home comprises three Victorian terraced houses linked together to a further Victorian detached house. The accommodation has three levels and provides 23 single and 3 double rooms, some of which have en suite facilities. There is a rear garden with a patio area and the home is situated in a residential area within walking distance of the local shops and other amenities. The city centre is also within walking distance. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection of the Home and lasted seven and a half hours. Discussions took place with the manager about how the home was progressing and records and policies were examined. Three staff were interviewed in private and four service users were seen in their rooms. One relative was also spoken with. Observations were made throughout the day in the lounges and dining room and some of the building was inspected. In addition the Commission sends out survey forms to service users and their relatives and to health professionals who know the home. Five service users, five relatives and five health professionals responded. Their views have been incorporated into the report. Information on the Commission’s own record received since the last inspection has also been taken into account. The home also provided a lot of information to the Commission which greatly helped in the inspection process. In February 2007 the sale of the home was completed and a new proprietor has been registered. The same manager has stayed in post. Overall this is a good service and provides a comfortable and caring environment to those accommodated. Service users are very happy with the home and although there are still some matters to be attended to, overall this is a good home. What the service does well: The service is good at seeing that they receive relevant information about the service users to make sure they can cater for their needs and make them comfortable. This information is then turned into a care plan which all staff work to ensuring that service users are carefully monitored. The home does particularly well in monitoring the health care needs of the service users and working with health professionals in the community who gave good accounts of the home in their contact with them. Service users are happy and well cared for and gave a very positive view of the home. “I like it here – the staff are very pleasant and friendly”, “I can’t fault the home”, “Everything here is good- I have no grumbles at all” and “I have no regrets at all (about coming here) – I feel safe and happy here” were some of the comments heard. They all spoke well of the staff and felt they were listened to and understood. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 6 The home has an excellent activities programme with outings and picnics, entertainers and parties. In addition there are in house activities every week including religious services and spontaneous games or craft sessions with staff. Where they can service users are encouraged to go out and keep in touch with previous contacts. Relatives are also welcomed and are encouraged to be involved in the outings and parties. Service users are protected by the home’s recruitment procedures and there is a good emphasis placed on training. Service users thought the staff cared for them very well. The overall management of the home is good with a strong commitment to good quality care and staff practice. What has improved since the last inspection? What they could do better: Clearer procedures about complaints and adult protection are needed and the paperwork on service users contracts should be kept. The routines about whether service users can stay in their rooms should be reviewed to ensure they are being offered a choice. The premises could be brightened up in parts and the crowding in the lounge should be looked at. The records of service users’ money should be better kept with tighter controls of how their money is administered. One to one supervision of staff needs to be more methodically introduced so staff welfare and performance can be better monitored. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 7 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. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 8 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 Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The information provided to service users is detailed and easy to read though the complaints procedure needs to be included. The information the home obtains before a service user comes to the home is very good and shows the home is making sure they will be able to assist the service user satisfactorily and meet their needs. EVIDENCE: A new statement of purpose and service users guide is in place having been brought up to date by the new owner. They give good easily understood information about the home. The one item missing however is the complaints procedure which needs to spell out how the home will deal with complaints and where they may contact the Commission. A requirement has been made. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 10 A sample contract was seen showing what the terms and conditions of the home were but copies were not kept on individual files, making it difficult to know whether service users had received them. One file had a note verifying that the contract had been given and the manager confirmed that all service users did receive a copy of the terms and conditions. When service users were spoken to they did confirm they were aware of the terms and conditions or their family did. However it would be better if the home kept a copy of the signed part of the contract showing that service users had been given the information. A recommendation has been made. Three care records were sampled and showed very good documentation on the needs and abilities of the service users showing that an assessment had been completed before the service users were admitted. Initial information was seen both from social workers and from medical personnel to help the home in deciding whether it could provide for the needs of the service users, but also the home itself completed a very comprehensive document following its own assessment of the service user both before admission and in the early days of residence. The assessment covered a wide range of subjects from mobility and all aspects of physical health to social activities, contact with family and religion. Overall these records were very good. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Overall this home is very attentive to the care needs of the service users with especially careful monitoring of health care needs. Care plans are comprehensive giving staff helpful information to enable them to meet the service users needs and medication is being administered correctly. Service users in unison felt they were cared for very well with proper regard to their dignity and privacy and spoke extremely well of the staff. EVIDENCE: Care plans were seen on the files sampled and were generated by the considerable assessment carried out by the home. As well as health aspects, social care and leisure preferences were also recorded. Risk assessments were in place relating to falls and to skin deterioration. These plans were reviewed monthly by the staff and six monthly by the manager. Daily reports on how the service user was faring were written by staff on each shift. Overall the service users needs were monitored very effectively by the use of these records. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 12 Five health care professionals returned a survey form sent by the Commission. All five felt the home worked in partnership with them and had a clear understanding of the care needs of the service users. All four service users interviewed mentioned contact with the nurse or situations where they had seen the doctor. Two district nurses were seen on the premises on the day of the inspection. The manager also gave details of visits by opticians, dentists and chiropodist as well as access to physiotherapists if required. The records showed that the home monitored carefully if a service user was prone to falls and the manager confirmed she has attended the falls clinic at the hospital to seek a remedy for a service user. Risk assessments for pressure sores were also in evidence and the manager reported that none of her service users have them. A nutritional assessment was part of the overall information collected and staff monitored how well service users were eating. Hospital beds were also seen in a few rooms because of the need of the service users. In addition the home currently is offering an exercise programme once a week which service users can attend. Staff confirmed that when they come on duty and have a handover with those going off duty, they discuss the care and health needs of the service users to ensure actions are followed through. This is the sort of practice that should be in place and the Home is commended for that. Overall there was excellent promotion and maintenance of service users’ health with good liaison with community health professionals. In the past twelve months there has been a serious problem with the administration of medication and the Commission required that major improvements be made in the recording and security of medication. On this visit, medication policies were seen to be in place and the medication was seen to be locked away in a drugs cabinet and in a locked room. Only dedicated staff are allowed to give out medication after they have been trained and staff interviewed confirmed these requirements. The administration of medication was checked and found to be correctly recorded. Tablets are in pre packed bubble packs and those sampled were correct. Controlled drugs are recorded separately and by two staff. The total number of tablets are noted each day and at change of shift showing the home is monitoring them carefully. A returns book documents those tablets returned to the pharmacist. None of the service users are self medicating at present though the home does have a risk assessment for this purpose. Overall medication was being dealt with satisfactorily. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 13 In terms of service users’ right to privacy and dignity, all service users seen and those answering the survey felt they were treated respectfully and they were assisted in private. They were able to see relatives and doctors in private and staff were seen to wait following a knock on their door. All service users have keys hanging from their doors but there did not seem to be any substance to this as no one seemed to use them. Service users did not seem to mind about this but as a practice it should be fully discussed with service users to ensure those who like their privacy in their rooms and want to lock their rooms when not in them can do so. A recommendation has been made. Overall though all service users felt the staff were extremely caring and felt kindly treated and respected. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have a pleasant lifestyle in the home with comfortable routines and excellent social activities. There is good contact with relatives who are welcomed into the home and the food has improved with more choice at meal times. One or two recommendations have been made to review routines but overall this area of daily life and social activities is judged to be very good. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 15 EVIDENCE: Both staff and service users said they were happy with the routines and service users could get up and go to bed when they liked. The manager was especially firm on this as she felt service users should not be ruled by any procedures in the home. One staff was able to show the flexibility of the routine at bedtime by describing some of her duties and how many service users she helped to bed and how many were still up when she went off duty. One routine which was viewed differently by the staff than the service users was that service users thought they could only have one bath a week though one or two who are self caring can decide for themselves. The manager said that some people did have two or three baths a week. Nevertheless those service users seen thought one a week was their entitlement and more consultation needs to take place to ensure service users are having showers and baths as they want. A recommendation is made to review this. Another routine seems to be that all but one or two service users stay downstairs during the day and have all meals downstairs in the dining room. For many this might be their choice, one service user telling the inspector she “liked to be with the crowd”. However it is hard to believe when the lounge seems particularly overcrowded, (see comments in the premises section), that some service users would not wish for more privacy in their own rooms, happy in their own company, and enjoy breakfast or tea in private. A recommendation is made for the manager to look at how choices like these are made and ensure that staff are not out of habit, expecting service users to be with the crowd. In terms of the entertainment and opportunities for leisure, this home is doing extremely well. An impressive list of outings and entertainers, picnics and parties were seen not only on their list of activities for 2006, but also for those planned for 2007. Service users commented about the outings though one or two said there was not enough to do and five out of six of those replying to the survey said the home was “always” arranging activities. Staff confirmed that in addition to the formal programme of activities they also have an exercise session once a week, bingo about once a month, cards, reminiscence and craft. Staff said they did something most days even if only three or four service users wanted to join in. The staff member responsible for this programme was interviewed and she described some of the in house activities. Baking was very popular and reminiscence worked well. She had a host of ideas and is a real asset to the home. Overall stimulation is very good in this home. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 16 Service users were able to discuss their involvement with their families and how often they came to see them. Records showed that the home was aware of interested relatives. The manager thought the families were very good and involved in the life of the home. A few returning the Commission’s survey said they felt welcomed and consulted. Service users felt quite happy with the home and felt they were offered choices in the routine, in their meals and whether they wanted to participate or not in activities. They were able to bring in their own personal possessions and look after their own affairs without home interference. Most have relatives or advocates to act on their behalf. Apart from a recommendation in this report for the home to encourage greater independence for service users on particular matters, the service users do have a good degree of autonomy and choice and certainly the impression from the manager is that she would always want to promote this. Requirements had been made at the last inspection to keep better records about the food offered and to offer service users more choice on the menu. At this inspection menus were provided showing a choice of menu at the main meal and at teatime. For breakfast service users said they usually had cereal and toast. Service users were enthusiastic about the food though unsure as to whether they had a choice at the main meal. On the day of the inspection however service users were seen at their meal and two different dishes were seen being consumed. The menu was displayed in the dining room. The cook was also spoken with and she confirmed that choice of menu was available every day. She said the teatime meal was also more varied now. An example of the home being flexible in offering food was provided when a new person was given something completely different from the menu at their request, the home being aware of previous problems with eating and anxious to encourage the service user. The home caters for diabetic diets and a few have soft food. Overall there were no complaints about the food, the service users saying it was “ good” and “lovely”. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. In practice service users were very content and felt they were treated well and properly. The paperwork on the complaints procedure and on the adult protection procedure was however in need of amendment to make sure service users and staff were clear about what to do. EVIDENCE: A word about complaints is mentioned in the guide and statement of purpose but it is not written out fully enough neither does it include the address of the Commission. Service users said they would talk to staff if they had concerns and were clear that they had no complaints about the home. Nevertheless they should have access to a straightforward step by step procedure. A requirement for this has already been made in Standard 1. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 18 Procedures are in place for safeguarding service users from abuse but they are not up to date without mention of the liaison with the multi agency adult protection unit. The manager was able to confirm though that she was aware that any suspicion of abuse is referred outside to the unit and has had to do this in the past. Staff records and those staff spoken to all confirmed that they had had training on adult protection and did understand the standards of care expected. It was rather the paperwork that was not correct and a revised policy should be written ensuring that the procedure refers to referral to the outside agency and notification to the Commission. Staff should also know that if they are found unsuitable to work that the home has a duty to refer for consideration on the Protection of Vulnerable Adults register. A requirement is made. Other policies dealing with whistle blowing and violence at work were in place. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The premises are well maintained though some areas need redecoration. The home is cosy though communal space is crowded. While service users are comfortable and the management ensures that the home is safe and well maintained, improvements can still be made to the building. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 20 EVIDENCE: A tour of the premises was conducted and all parts of the premises were found to be clean and well maintained. Some rooms have been recently decorated and it is recognised that there is need for further improvement. Some bathrooms are in need of modernisation, though a new bath and shower facility has been installed on the ground floor. A recommendation has been made. Service users’ rooms vary with some being more cosy and individual than others. The main weakness of the home is the lounge area which is one large room and although divided into different areas appears very crowded. There is a large comfortable dining room which is underused except at mealtimes. There could be other possibilities in the use of space to create more choices for the service users, and it is recommended that this is reviewed. For example it would seem that more space could be created if the dining room was made into another lounge and the back part of the main lounge made into a dining area. This would provide more choice in sitting area and space. There is a rear garden with seating and this is pleasant in the summer. The home also has guarded radiators and hoists and lifts to make life easier for those with mobility problems. The home complies with the requirements of the local fire service and environmental health department. One double room being used as a single still had two beds in it taking up space which the service user could use. Another bedroom had no call bell. Both these matters were raised with the manager who agreed to deal with them. Overall the building has some flaws but is safe and reasonably well maintained. The home is kept clean and hygienic and is free from odour. Laundry facilities are good with an industrial washer with a sluice wash and a tumble drier. Only personal laundry is carried out, sheets and towels being sent out to an outside laundry. Staff have received infection control training and appropriate disposal bins are used. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 21 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): 27,29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skill mix of staff and are supported by the home’s recruitment policy. Training is regularly provided though recording needs to be tighter. EVIDENCE: The rota for the week of the inspection was examined. There are normally three care staff on all day until 8pm when two are on duty the rest of the evening and throughout the night. On five days there is in addition a senior carer and the manager is on duty during office hours in the week. The home is currently accommodating 25 service users and the hours are considered to be satisfactory for that number. Should the home accommodate the 29 service users they are registered for, the number of hours provided would be slightly under that required including catering hours. Staffing is evenly spread and staff spoken to felt they did have enough time to attend to service users and were not rushed. Service users felt well cared for by staff and spoke very positively about them. The recruitment files were examined for two staff and found to contain the relevant checks and references including a criminal records check. Staff confirmed they are issued with the code of practice of the General Social Care Council and the home also issues them with a handbook about procedures in the home and their terms and conditions. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 22 A great deal of training has taken place during the last year with full details of the training provided for the inspector. Staff records confirmed the training courses attended. Induction training was seen and the home is following the new Common Induction Standards. However the completion of the induction was not recorded and it was not possible to tell whether new staff had completed the training. A requirement is made. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 23 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): 31,35,36 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The quality of the management is this home is very good but the manager has had to work hard to turn the home around from poorer times. There is still some work to do in the administration of the home. Better safeguarding of service users money and better supervision of staff are two areas which need to be improved. Health and safety is given a high priority. But overall service users live in a home which has their interests at heart. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager has only been in post since July 2005 and came at a time when the home badly needed better direction. She has successfully improved the home working hard on the care offered to service users and the records concerning care. Training has improved and she has an inclusive approach whilst setting high standards. Staff confirmed they could approach her with their ideas or concerns. She acknowledges she still has things to do. The quality assurance system was not scrutinised on this occasion though the home will need to have standards for quality that it can measure. They do have in place a questionnaire for service users which will give them an idea about how the home is faring. Any deficiencies will be expected to be reflected in an improvement plan in the future which the home will have to send to the Commission. The home looks after money on behalf of all the service users though mostly for safekeeping rather than administration. This was considered old fashioned and not encouraging of independence and a recommendation is made to find ways to promote service users looking after their own money with the provision of locked facilities in their rooms for example. Two records were checked against the cash held. One was satisfactory, but the other had several mistakes though money was over in the purse. When receipts for money spent were checked, it also emerged that staff held on to money for a service user anticipating that they would be taking them out shopping. This is a dangerous practice and to protect the staff and service user a much tighter system must be put in place. Overall the financial interests of service users were not safeguarded enough and a requirement is made. Although there was patchy evidence of one to one supervision of staff, a full system is not yet in place. Staff confirmed that they had easy access to the manager but had not seen her on a regular formal basis. The manager accepted that supervision had not been as systematic as she hoped as she had been more focussed on improving the standards of care in the home. She has received training on staff appraisal and performance and expects to sort out the supervision of staff in the near future. A requirement has been made. Staff did however confirm that they had handover meetings between shifts to ensure continuity of care and that they had had staff meetings. Both of these components help staff to improve their work. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 25 The home has appropriate health and safety procedures in place to safeguard both service users and staff. Safe working practices are ensured with staff records confirming that training in moving and handling, first aid and fire safety is provided. The cook confirmed she had a food hygiene certificate as have a few other members of staff. Fire records showed regular fire drills and tests, safety certificates were seen for gas and electrical appliances and the lift is regularly serviced. Risk assessments for the building were seen and an accident record is kept. A recent environmental health officer’s visit report was seen. The manager confirmed that all issues had been dealt with. Overall the health and safety of those within the building is satisfactorily promoted. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 26 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 2 2 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 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 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 1 2 x 3 Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 27 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 OP1 OP16 Regulation 22 Requirement The registered person must supply a copy of the complaints procedure to every service user, detailing the actions to take and including the address of the Commission. The registered person must ensure that they have a clear policy about adult protection that reflects current practice in terms of referral to outside agencies. The registered person must ensure that staff receive training appropriate to their work. In this instance, induction training was not adequately completed or recorded. The registered person must ensure that safeguards are in place to look after the service users money. In this instance records were incorrect and cash held with staff. The registered person must ensure that staff are appropriately supervised. In this instance, staff should have the opportunity to meet with a senior every two months. DS0000069104.V331676.R01.S.doc Timescale for action 30/04/07 2 OP18 13(6) 30/04/07 3 OP30 18 30/06/07 4 OP35 17 30/04/07 5 OP36 18(2) 30/06/07 Whitehall Lodge Residential Care Home Version 5.2 Page 28 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 5 6 7 Refer to Standard OP2 OP10 OP12 OP12 OP19 OP19 OP35 Good Practice Recommendations It is recommended that a copy of the contract issued to service users is held by the home. It is recommended that service users are consulted and informed about the use of their keys so that they can have more privacy if they wish. It is recommended that the frequency of bathing is reviewed with service users to ensure they are satisfied. It is recommended that it is reinforced with service users and staff that they can stay in their rooms as they wish and be private and alone. It is recommended that consideration is given to redecoration of parts of the building. It is recommended that the use of communal space is reviewed to see whether more choices can be offered to service users. It is recommended that locked facilities are provided for service users so that they can look after their own money. Whitehall Lodge Residential Care Home DS0000069104.V331676.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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