Inspection on 16/02/06 for Whitehaven Lodge

This inspection was carried out on 16th February 2006.

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

Whitehaven Lodge 15/05/09

Whitehaven Lodge 15/05/08

Whitehaven Lodge 16/05/07

Whitehaven Lodge 20/11/06

Whitehaven Lodge 18/05/06

Whitehaven Lodge 22/09/05

Whitehaven Lodge 03/02/05

Whitehaven Lodge 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Whitehaven Lodge Buttermere Close Maybush Southampton Hampshire SO16 9JR Lead Inspector Christine Hemmens Unannounced Inspection 16th February 2006 10:00 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 Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Whitehaven Lodge Address Buttermere Close Maybush Southampton Hampshire SO16 9JR 023 8078 4839 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) Southampton City Council Mrs Lorraine Tew Care Home 55 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (55) of places Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of eight service users in the category DE(E) may be accommodated at any one time. Three service users in the DE category may be accommodated between 60 and 64 years of age. The home may admit one agreed service user (date of birth 01/04/47) for short-term care only. 22nd September 2005 Date of last inspection Brief Description of the Service: Whitehaven Lodge is a large purpose built residential home providing care and support to 55 elderly persons, some who are frail and have dementia relating to their old age. The home is located in Millbrook, the west of Southampton, approximately 2 ½ miles from the city centre and is managed by Southampton City Council. The building is laid out over two floors with a passenger lift access to the first floor. It was built in 1981. Recent renovations to the home now allow residents to be accommodated in single rooms. Bedrooms are arranged in 6 separate living units. On the ground floor there is one large dining room and four smaller lounges, one of these is a smoking lounge. There are 3 separate unit-living facilities available on the first floor, each with its own kitchen and dining facilities should residents wish to prepare drinks or snacks and retain or regain their independent living skills. The home has a pleasant garden, which incorporates a raised sensory flowerbed and a lawn. Garden furniture and a handrail enable residents to enjoy the garden to the full, particularly during the warmer months. The home also has its own shop, which is open twice a week, and on request from residents, however residents when staffing levels allow are supported to go out to the local shops if they wish. There is a library area, an arts and hobbies room and hairdressing facilities. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced visit to the home in twelve months. The manager Mrs Tew was available at the time of the visit and assisted with the inspection process. The inspector was invited to join a management meeting, which provided useful information on how various procedures and systems worked within the home and values of the senior staff. The inspector met with a resident and their visiting relative and took a brief tour of the home. What the service does well: What has improved since the last inspection? Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 6 Unfortunately the home has done little to improve on the requirements issued following the previous inspection. However some redecoration has occurred in one of the lounges, kitchenettes and some bathrooms. The home appears cleaner and the domestic staff are regularly monitored to ensure they are cleaning areas of potential cross infection thoroughly. The holes in the floor where firewater hoses had been removed have now been filled and made safe and the home is exploring ways in which more vulnerable residents can be protected from the risk of harm if they were to leave the home unescorted. What they could do better: The home could do better to meet the requirements issued following inspections. Following this visit to the home it was issued with twelve requirements, eight of which have been repeated and one of which has been repeated for the fourth time. The inspector found that there has been no significant improvement in the standard of care planning and providing information on residents for staff in a way that will enable the staff to fully meet the health and welfare needs of the residents. Therefore the home could do better to ensure an appropriate and full assessment process is undertaken on prospective residents. Staff should be made aware of the strengths and needs of the residents in order to promote their independence, meet their specific and individual health and welfare needs in the way that they wish and appropriately evaluate the outcome of care for the resident. The home must do better to demonstrate that it has made residents fully aware of their rights whilst living in the home, by ensuring the statement of terms and conditions of residency are completed correctly and signed by the resident or resident’s representative and the manager. The home could do better to ensure all staff are made aware of the values of privacy and dignity, where necessary provide training for staff and provide an appropriate place to discuss personal issues with residents and relatives. The home could do better to provide an environment that is comfortable, aesthetically pleasing and safe. The home has been issued on three previous occasions with a requirement to provide the Commission for Social Care Inspection with an action plan on how and when they intend to improve certain areas of the home. To date this has not been actioned, therefore another requirement has been issued and a decision will be made to consider enforcement action. The previously made requirement to fix appropriate Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 7 mechanisms to hold open fire doors to residents’ bedrooms and cease the use of props has not been met, therefore placing the residents at risk of potential harm if the home were to catch fire. Therefore the service must without delay install the appropriate mechanisms as required. The home does well to involve residents in decision-making and regular audits of the home are undertaken by a senior manager in the organisation to monitor outcomes for the residents, however the home could do better to formally seek the views of residents, residents’ representatives and visiting professionals. The home could do better to ensure that there are at all times enough skilled and appropriately recruited staff in such numbers to meet the health and welfare needs of the residents. The home remains short staffed and relies heavily on agency staff to backfill gaps in shifts. Although the home uses agency staff that are familiar to the home, with the home’s current poor care planning procedures this does not allow for a consistency of care and support. The home must undertake robust recruitment procedures, demonstrating that it has made all the appropriate recruitment checks including CRB, POVA and history of employment. Serious consideration will be given to taking enforcement action. 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. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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 Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3, and 6 The service provides residents with a contract of terms and conditions of residency, however the home must ensure all documentation is fully completed. The home undertakes an assessment process prior to admission and monthly there after to ensure the home can meet the residents needs and continuing needs, however the home must ensure the documentation reflects the actual needs of the residents. The home does not provide intermediate care. EVIDENCE: The inspector was informed that the home had recently undertaken an audit on all contracts held within residents’ personal information to ensure they had been issued with the most up to date contract. These included date of occupation, the room, which the resident occupies, the fee and evidence of signatures by the resident, resident’s representative and the manager. However the inspector found some inconsistencies on two of the three Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 10 contracts viewed, one resident did not have a commencement date, another was not signed by the manager. The home accommodates up to fifty-five residents, two of the three contracts viewed had not been completed fully, therefore the requirement issued following the last visit to the home will be repeated, a further failure to comply will result in further action being taken. The home is advised to undertake a further audit of the residents’ contracts to ensure they are appropriately completed. The home undertakes an assessment prior to a resident taking up occupancy, this is followed up by a day assessment when the resident visits the home to establish if the service can fully meet their needs and if they are happy to move in. The home continues to monitor the residents’ health and personal care needs on a monthly basis using the “Bartel” assessment documentation. The inspector viewed three assessment plans and identified that the documentation had not been completed correctly giving an incorrect scoring. In addition the information provided at the pre assessment stage and the residents’ personal plan gave conflicting information to that indicated on the “Bartel” assessment. The inconsistent approach to assessing the residents’ needs places the residents at potential risk of not having their needs appropriately and adequately met. The registered manager must consider if this is a training issue for her staff. The home was required following the previous inspection of the home to ensure that the assessment documentation was thoroughly completed, although some improvement has been made the requirement will be re-issued due to the inconsistent and conflicting information provided. Further failure to comply may result in further action being taken. The home will involve care professionals to undertake other forms of assessment such as nursing needs if a resident requires it. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The home is making progress to ensure residents receive their medication appropriately, however the home continues to fail to demonstrate through the residents personal plans that they are adequately meeting the health and welfare needs of the residents. Concerns remain regarding the homes demonstration of the values of privacy and dignity EVIDENCE: The inspector viewed three residents’ personal care plans as part of the inspection process and established that the staff continue to fail to adequately complete care plans to truly reflect the residents’ strengths, needs, personality, and “how” the care must be carried out. Of the three plans viewed by the inspector not one had been completed to a good standard. The personal plans do not reflect the information obtained in the assessments and reassessment documentation or give guidance on how the resident wishes to have their care carried out. For example the inspector was informed that one resident had Parkinson’s and required their medication early in the morning to assist their mobility before they get up. However this was not reflected in the Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 12 plan of care, nor the Bartel assessment and the task plan. Furthermore the continence care, foot care, moods and health care did not provide adequate information to give guidance for staff. This was discussed at length with the manager as a serious concern due to the potential detrimental effect on the residents. Through the course of discussion it was identified that the manager has assigned a care coordinator to quality audit the plans and organise the residents personal files systematically to assist staff to obtain the information they require, however it was established that there is a training need for all staff. The requirement to ensure risk assessments reflect the individualised and specific area of need has been met. Later the manager addressed the concerns regarding the care planning process in a staff management meeting. The manager was made aware that the requirement would be repeated for a third occasion, which could result in enforcement action being undertaken. The home has recently adopted a new medication administration system and changed pharmacy suppliers. The care coordinator responsible for the ordering and monitoring of medication spoke highly of the new administration system, improving the system for administration, ordering and returning medication. The carers confirmed that the new system had not started without its problems, however these had now been resolved and the system was proving to be more manageable than the previous system used. The staff stated they found the pharmacy supplier was very supportive, provided initial training and delivers additional medications at short notice. Following the previous visit to the home, it was required to consider the values of dignity, privacy and respect. The home has done well to provide evidence in writing and signed by the resident that they have been consulted if they wish to hold their personal plans or allow the home to hold these on their behalf. However the concern with regards to the residents’ personal details being discussed openly in front of others and the discussion to be overheard by others remains. The inspector again witnessed and overheard personal information being discussed openly in a communal area. The manager was notified of this as it was happening and dealt with the situation immediately. The manager must consider if this is a training issue for staff. The requirement will be repeated a further failure to comply will result in enforcement action taking place. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The home does well to provide an environment that stimulates, provides a welcoming environment for friends and relatives and ensure the nutritional needs of the residents are met. EVIDENCE: The inspector met with a resident and her visiting relative. They were both very complimentary of the care, the staff dedication and the activity within the home. This was supported by the care coordinators who have specific roles within the home to organise special events and activities in and out of the home and to ensure the residents receive a wholesome and well balanced diet. The inspector was provided with many examples of the activities residents are encouraged to participate in. The inspector was informed and saw evidence in minutes of residents meetings that they are consulted about the activities they would like to have. The resident with whom the inspector spoke with said she had attended the recent Valentines Day party and had thoroughly enjoyed the old time music and the buffet tea provided. She said she especially enjoyed listening to the staff trying to sing on the karaoke and watch them dancing. The home is well known within the local community and has links with the local schools that also provide regular entertainment for the residents. The inspector Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 14 was informed that several boat trips had been organised for this year, which is an event the residents appear to really enjoy. Residents can attend church services of their choice and services are held regularly in the home. The manager informed the inspector that they had recently received a referral to take a resident of a minority ethnic origin and were already considering how they could effectively support the religious and dietary needs of the prospective resident, however the home must ensure that the assessment needs are well documented and reflect the plan of care. The resident with whom the inspector spoke with said that the food was very good, this was supported by her visiting relative whom commented, “the food looks so good I have cheekily asked if I could stay for dinner”. The manager informed the inspector that one of her care coordinators is responsible for monitoring the kitchen, its efficiency, health and safety, menu planning and quality of the food. The inspector was informed that the cook will meet with the residents on admission to the home to establish their dietary requirements, their likes and dislikes, appetite, cultural and religious requirements, special equipment and any assistance they may require. If the dietary needs of a resident change that affects the health care needs of a resident the home will call upon a GP, district nurse and/or dietician for assistance. The home must ensure care plans clearly reflect special dietary requirements and “how” the resident is to be assisted if help is required. The manager may wish to consider training her staff in nutritional needs of the elderly and residents with dementia. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home demonstrates that it takes all types of abuse seriously. EVIDENCE: Please refer to the report dated the 22nd September 2005 to provide information on how the homes deals with complaints, concerns and training relating to abuse. The manager informed the inspector that the service was still in the process of investigating the concerns in relation to the thefts that occurred April 2005 to September 2005. The manager advised that she is to meet with the head of services, the police and a colleague who is a manager of another City Council home to address the problems experienced previously and how a more efficient approach can be undertaken in the future if required. In addition to addressing the alleged thefts the home is taking steps to improve the security of the home. The home is currently open and visitors come and go throughout the day. A number of residents have left the building without notifying the staff of their whereabouts. Some residents have placed themselves at risk by leaving the home unsupported. The manager informed the inspector that steps are being taken to minimise the risk to residents leaving the building and placing themselves at harm and minimise the risk of unwanted visitors entering the building. A long debate took place later in the day with care coordinators who shared equal concern for the more able residents having restrictions placed on them by the limited exit and access to Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 16 the home. The manager is to confirm what steps are going to take place to ensure restrictions placed on more able residents are limited. The manager is required to evidence that consultation with residents has taken place. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The staff attempt to provide a warm, hygienically clean and friendly environment for the residents to live, however there are a significant number of outstanding environmental improvements that have to date not been met. EVIDENCE: The inspector viewed areas of the home that have recently been redecorated by a voluntary service, this included some lounges, residents kitchens and some bathrooms. A resident informed the inspector that she liked the colour of the lounge and found the home to be comfortable. Another resident informed the inspector that she liked her room and the staff keep it very clean and tidy for her. Following the previous visit to the home in September 2005 four requirements, two of which have been repeated on three occasions were made in respect of the environment, including: 1. Upgrade and redecorate the breezeblock interior 2. Make aesthetic improvements to the bathrooms and toilets Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 18 3. Replace carpets. The manager confirmed that on several occasions the home had been visited by the maintenance department to assess the works required, however to date she had not been given a time when the work will be carried out. Previous to this visit to the home the Commission for Social Care Inspection regulatory managers and inspector met with Southampton City Council maintenance department and senior managers to discuss the issues surrounding the work required to make improvements. It was agreed that the Commission for Social Care Inspection would be provided with a schedules of work with time scales, however to date this has not been received. Therefore the requirement to provide us with details on when the work will be carried out will be repeated. Further discussions will be had with regulatory managers with regard to enforcement action being taken. In addition to improving the environment the manager was required to make safe the floor in the kitchen, this was following a serious injury to a member of kitchen staff. A temporary repair has been made to the floor and the manager advised that the floor will be replaced along with the kitchen in April 2006. During the course of the inspection the inspector met with senior staff, each care co coordinator described their specific role within the home. One of these is to be responsible for the domestic staff and ensure the home is kept clean throughout. The member of staff discussed what steps they had taken to improve hygiene standards and their attempts to eradicate unpleasant smells. Replacement carpets are required in the entrance area to the home as it is worn and the staff have difficulty eradicating unpleasant odour from this area. The care coordinator informed the inspector that the schedule of cleaning had been improved and checks regularly made to ensure all cleaning tasks are undertaken to a high standard. Additional cleaning products had been purchased on the day of the inspection to attempt to thoroughly clean plugholes and the underneath of bath hoists. This is a demonstration that the home is trying to meet good standards of hygiene. The care coordinator confirmed that staff are issued with gloves, aprons and antibacterial hand gel to prevent the spread of infection. A recent outbreak of a seasonal D & V infection called upon the services of the environmental health department who were reported as being impressed with the home’s prompt action to eliminate the spread of the infection. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 The home attempts to meet the needs, dependency levels and safety of residents with skilled, appropriate numbers of staff who have been recruited appropriately, however evidence suggests that not all staff have had appropriate recruitment checks carried out on them. EVIDENCE: The service remains short of staff and relies heavily on agency staff to cover shifts, this remains a concern for staff as they feel they are unable to provide the quality and consistency of care they want to give. The home is currently addressing this problem until new staff are recruited by reducing its numbers of residents admitted to the home. The home is registered for fifty-five, however is currently supporting fifty residents. The home has a separate team of catering and domestic staff however they are currently short in these areas too. The manager confirmed that the service had recently recruited a large number of staff and were waiting for recruitment checks to come through before starting them. This will be viewed again during the next visit to the home. The manager ensures it staff receive appropriate training to meet the needs of the residents. This was confirmed by a resident who stated “the staff appear to be very knowledgeable and know what they were doing”. In addition the staff are supported to undertake a National Vocational Qualification (NVQ) in care at level 2 and senior staff are encouraged to undertake level 3. Over 50 of staff working in the home have achieved NVQ. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 20 The manager appeared fully aware of the recruitment procedures and that staff could not commence working in the home until all appropriate checks had been undertaken, however on viewing newly appointed staffs personal file discrepancies were found that raised concerns that appropriate checks were not being followed or made correctly. There was no evidence to suggest that a Criminal Record Bureau check (CRB) or Protection of Vulnerable Adult check (POVA first) had been undertaken on the newly appointed staff. Application forms were either not available or were not completed correctly, gaps in employment had not been verified by the manager. The manager confirmed that the services human resource department were getting better at sending information through, however the manager must ensure she is happy that all checks have been undertaken before starting staff in the home. This poses serious concerns as the service repeatedly fails to comply with required minimum standards and regulations and places residents at potential risk of harm. The manager stated she has recently nominated one of her senior staff to undertake the task of checking that all staff have an up to date CRB. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 The home is managed by an experienced manager, who attempts to ensure the home is managed in the best interest of the residents in a safe environment and by staff that are appropriately supervised. However further improvements must be made to the environment to ensure the health and safety of the residents and staff. EVIDENCE: Mrs Tew the registered manager has worked in the capacity of the manager of Whitehaven Lodge for approximately seven years working in an acting position for a short period of time before being appointed as the day-to-day manager. Mrs Tew demonstrated throughout the course of the visit that she is an experienced manager who has undertaken an NVQ 4 in care and management and attends regular training to update her skills. The manager held a management team meeting on the day of the visit this was conducted Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 22 professionally and care coordinators were encouraged and appeared comfortable to share their views and offer ideas. The manager asked her staff to inform the inspector of their specific roles and fed back how the inspection was going, this led to healthy discussion on how they were going to achieve the requirements identified so far. In order to establish if the home is meeting the needs of the residents the home holds monthly resident meetings, which are minuted. The minutes evidence that a range of topics are discussed including menus, entertainment, staff and any concerns the residents might have. A record of the homes response and actions are also recorded. The service has an accessible pamphlet for the residents and their families called “Your Views Count”. This encourages residents and their families to make suggestions on how they can improve the service through compliments and making complaints. This demonstrates the service is open to suggestions. However the home does not undertake a specific quality audit that seeks the views of residents, relatives, staff and professional visitors. Discussion took place with the manager and some of her staff on how this could be achieved and the manager was making suggestions as to what they could do at the time of the visit. The manager is required to undertake a quality audit and forward a copy of the concluded report to the Commission for Social Care Inspection. The home supports a large number of residents with their personal finances, an effective system has been in place for approximately a year that provides a clear audit trail of how the residents monies are managed including benefits, income and expenditure. The homes administrator talked the inspector through the system and appeared very knowledgeable and confident in the process. Large amounts of money are not held on the premises and those residents who manage their own financial affairs are regularly advised on its security. Lockable storage is provided for those residents who manage their own finances. During the course of the meeting held by the manager the care coordinators were advised of their roles of supervisees and the target of the number of supervisions undertaken last year and the expected target this year. The inspector was informed that deficits were due to staff absences and on the whole the service had done well to ensure staff are appropriately supervised. The manager informed her management team of her expectations for the coming year and the type of issues that need to be discussed through supervision, this especially related to appropriate care planning. Following the previous inspection a requirement was made that designated fire doors were not propped open by inappropriate means. On this occasion it was again found that designated fire doors were held open. Designated fire doors must only be held open by approved devises linked to the fire safety system. The current practice allows the unimpeded passage of smoke and flame in the Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 23 event of a fire, and puts residents directly at risk. A further visit will be made to monitor this, and a failure to comply will result in enforcement action. The inspector saw evidence that all equipment and utilities are regularly serviced, staff receive specific training such as moving and handling, first aid and fire training and all corrosive substances hazardous to health ate securely locked away. The care coordinator responsible for health and safety appeared knowledgeable and informed the inspector that regular health and safety checks are undertaken on the building and faults immediately reported to the maintence. The manager now has access to records held by the maintence department. However the manager must ensure staff undertake recorded monthly visual checks on fire extinguishers. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 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 1 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 x 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 x 2 Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 25 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 OP3 Regulation 14(1) Requirement The registered manager must ensure that all staff responsible for assessing new prospective residents and reassessment of their needs ensure they complete the assessment documentation correctly to accurately reflect the residents needs, to ensure they are able to meet their needs. This requirement has been repeated. A further failure to comply will result in further action being taken. 2. OP2 5 The registered manager must ensure all residents contracts, are fully completed, stating the date of admission, the fee, the room to be occupied and is signed by the residents or residents’ representative and the manager. This requirement has been repeated. A further failure to comply will result in further action being taken. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 26 Timescale for action 31/03/06 30/04/06 3. OP7 OP15 12(2) 15(1)(2) The registered manager must ensure records held for residents provide clear and accurate information, detailing how the resident needs and wishes to be supported. This requirement has been repeated. A further failure to comply will result in further action being taken. 30/04/06 4. OP7 14 & 15 The registered manager must ensure the plan of care reflects the assessed and reassessed needs of the resident. The registered manager must ensure all staff are aware of the values of privacy and dignity. Where necessary training must be provided. Relatives must be encouraged to talk about personal details pertaining to their relative in private. This requirement has been repeated. A further failure to comply will result in further action being taken. 30/04/06 5 OP10 12 31/03/06 6 OP18 13(7)(8) The registered manager must provide the Commission for Social Care Inspection with evidence on how they are going to limit the restricted practice of locking the front door for those residents who are able to leave the home unescorted. The registered manager must provide the Commission for Social Care Inspection a schedule of works that identifies DS0000039153.V260115.R01.S.doc 30/04/06 7. OP19 23(2)(d) 30/04/06 Whitehaven Lodge Version 5.1 Page 27 actions and times scales to upgrade and redecorate: The breezeblock interior. The bathroom and toilets. The carpets in corridors and identified bedrooms. This requirement has been issued on four consecutive occasions. Enforcement action will now be considered. 8 OP3 18(1)(a) The registered manager must provide the Commission for Social Care Inspection with details of the residents’ dependency levels and an action plan on how the home will fill vacancies and deploy staff effectively. This requirement has been repeated. A further failure to comply will result in further action being taken. 9 OP29 19(1) (a)(b) The registered manager must 31/03/06 ensure the home and the organisation follows the correct procedures, takes up and provides evidence that appropriate checks have been undertaken when recruiting staff, i.e. CRB and first POVA checks, gaps in employment. A failure to comply will result in enforcement action. 10 OP33 24(1)) (2)(3) The registered manager must undertake a quality audit of the service seeking the views of residents, relatives, staff and visiting professionals. A copy of the report must be Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 28 31/03/06 31/05/06 11 OP38 23(4) 13(4) forward to the Commission for Social Care Inspection. The registered manager must ensure all times that resident doors are not being held open by inappropriate means. A further failure to comply will result in further action being taken. 30/04/06 12 OP38 23(4) The registered manager must ensure monthly visual checks on fire extinguishers is undertaken and recorded. 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7OP30 OP15OP30 Good Practice Recommendations The registered manager must consider providing training for staff in care planning. The registered manager must consider providing training for all staff in nutritional assessing and dietary requirements in the elderly and dementia. Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitehaven Lodge DS0000039153.V260115.R01.S.doc Version 5.1 Page 30 - 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. 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