Inspection on 18/05/06 for Whitehaven Lodge

This inspection was carried out on 18th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 16/02/06

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 Chris Johnson Unannounced Inspection 10:00 18 / 19th May 2006 th 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.V289328.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.V289328.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.V289328.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 16th February 2006 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.V289328.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards and compliance with regulations and previous requirements. The findings of this report are based on a number of different sources of evidence. These included an unannounced visit to the home, which was carried out over two days on the 18th and 19th May 2006. During this visit a tour of the premises was completed that included looking at service user’s bedrooms and all communal areas of the home. Staffing and care records were inspected; staff were spoken with and observed in their interactions with residents. The inspector held a meeting with seventeen residents to discuss their experiences of life in the home. Several other residents were spoken with individually and ten residents completed questionnaires. Telephone interviews were held with seven relatives, a GP and a district nurse. Questionnaires were also sent to care managers. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? Safety has been improved since the last inspection with the installation of new fire doors. This means that residents will now be able to their leave their bedroom doors open if wish while being protected. Improvements were noted in the level of privacy afforded residents and everyone spoken with during the Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 6 course of this inspection said that they felt that residents’ privacy was respected. The inspector was satisfied that requirements from the previous inspection in respect of the physical environment were being addressed in line with the action plan submitted following the last inspection and several outstanding areas are due to be completed by the end of July 2006. Some improvement to the décor of the home has been made with the redecoration of bathrooms. An improvement in the home’s recruitment procedure has provided residents with greater protection. 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. Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 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 Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 and 6 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The opportunity for prospective residents to visit the home prior to moving in are good and are assessments are completed at this stage to ensure that their needs can be met. EVIDENCE: Whitehaven Lodge does not provide intermediate care. This standard is therefore not applicable and was not assessed. The files of four residents were examined during the visit to the home. All contained contracts informing them of their rights. Everyone who responded to the questionnaire said that they had been issued with a contract. All contracts had been dated and signed. It was noted that information regarding costs was incorrect. There had been a fee increase introduced on 24/4/06 and at the time of this visit residents had not received updated contracts to reflect this increase. Notification of this increase was however posted on notice boards. The manager was advised that new contracts should be issued as soon as possible. Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 9 Pre admission assessment and care notes were looked at for four residents. All residents had been assessed prior to admission to determine whether the home could meet their needs. In discussion with a group of seventeen residents the majority said that they had been able to visit the home prior to moving in. This was supported by feedback from resident questionnaires and feedback from relatives. One commented, “ My father visited for the day and liked it. The staff made him feel welcome”. Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. Residents consider their care needs to be met. However care planning is poor and does not provide sufficient information to ensure that all needs are met. The home does not ensure that they continue to keep residents needs under accurate review and cannot therefore demonstrate that they are meeting peoples’ needs. EVIDENCE: There was a general consensus from all residents that the home met their needs, although the home cannot demonstrate that this is the case. Residents support needs are reassessed monthly using the ‘Barthel index’. However care plans are not updated accurately to reflect assessed changes in need as there was conflicting information between the level of assessed need as indicated on the Barthel and the information provided on the residents’ personal care plan. This was highlighted at the last inspection and has not improved. Requirements were made at last the last two inspections regarding the lack of detail in care plans. An action plan was received following the last inspection stating that an audit of all care plans was being undertaken to ensure that care Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 11 plans accurately reflected residents needs. This was due to be completed by 30/4/06. However little improvement was found in the detail of any of the plans looked at. The care plans for four residents were examined. A full care plan was only available for three people. No care plan was available for one service user who had lived at the home for over a month and only a very brief risk assessment had been carried out. The three remaining plans lacked detail and guidance and did not fully address all assessed and identified needs or risks. Care plans differed in quality; the personal profiles and life histories were in depth and gave a lot of important information and there was evidence that all residents are consulted as to whether they wish to hold a copy of their plan. However the language used in one care plan was inappropriate and this was brought to the manager’s attention. Staff need more training in this area. In discussion with two members of staff responsible for key working residents and completing care plans, neither had received any training. Staff agreed that there were inconsistencies within care plans and they gave examples where one person’s care plan stated that they needed assistance when actually this was not required. One resident had specific needs related to impaired vision and the care plan did not adequately reflect this. Care plans do not provide sufficient detail regarding mental health or dementia care needs. Risk assessments were not in place for all identified risks e.g. residents with history of suicidal attempts and as previously stated care plans did not reflect residents assessed needs. Feedback from health professionals was that the home was generally good at contacting GPs and sought medical advice appropriately. Residents said that they had access to a range of services such as GPs, dentists, chiropodists and district nurses. Residents said that staff contacted healthcare support as and when they needed it and that it was dealt with for them. There would however appear to be a problem in ensuring that advice given by medical practitioners is acted upon in the first instance. Examples were given whereby instructions were passed on to staff to apply creams or ointments to residents. It was reported that this often has to be requested more than once. On one occasion the treatment had not been administered some two weeks after being prescribed. Evidence to substantiate these concerns were found from examination of care and daily recording notes. This would appear to be a flaw in the homes’ internal communication system and adds further evidence of the importance to include all needs within care plans. The inspector observed a senior member of staff while they administered medication. Medicines are safely and appropriately stored and only senior trained members of staff are permitted to administer medication. While generally medicines are well managed there were found to be some problem Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 12 areas. Procedures for the recording of medication are not always followed. Several residents have been prescribed ‘as required’ (PRN) medicines and there was not any guidance to inform staff regarding the use of these. Neither was it referred to in their individual care plan. Consequently the decision to offer PRN medication often rests upon the member of staff and this is clearly unsatisfactory. From examination of the recording sheets staff were using a variety of different codes to record PRN administration meaning that it could not always be established as to whether the individual had actually been administered the medication or not. Current practice is that one member of staff is solely responsible for administering medication at any given time. This means that the staff member has to leave the trolley unattended while taking people’s tablets to them. It was also noted that on several occasions the staff member signed the administration sheet prior to actually administering the medication. This is poor practice. The staff member was also observed to have to return to several residents to ensure that they had taken their medication. It was also noted that at weekends there is only one senior member of staff on duty at any given time. From discussion with one senior member of staff they commented that this could be problematic if an incident arose needing their attention at the same time as they were administering medication. These problems highlight the need to have two members of staff supervising medication at any given time. Due to the large number of residents this would seem a much safer system. Everyone spoken with during the course of this inspection said that they felt that residents’ privacy was respected. Health and social care professionals and relatives reported that they could always see people in private. All residents spoken with said that their privacy was respected and the inspector observed this to be the case throughout the visit to the home. Whitehaven Lodge DS0000039153.V289328.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 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The meals in the home are good, offering both choice and variety. The opportunity for residents to receive visitors is good and residents are free to make their own decisions about how they spend their time and are supported to engage in a variety of activities. EVIDENCE: The opportunity for residents to keep in contact with their friends and relatives is good. All relatives spoken with said that they could visit the home whenever they wished and that they were made to feel welcome. Generally relatives said that they were kept informed of any important matters affecting their relative although one person spoken with felt that this could be improved. Generally residents reported that they were happy with the standard of food that the home provides. During a group meeting of seventeen residents there was a general consensus of opinion that the food was good. Residents did say that the regular cook was extremely good. However they were in agreement that on days when the regular cook was not working and was replaced by an agency cook the standard noticeably declined and that they could tell the difference. Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 14 Residents are offered a choice of meal and they said that staff check with them everyday as to their preferred choice of main and evening meal. Copies of menus were sent to the Commission for Social Care Inspection prior to the visit to the home. These demonstrated that the home offers a varied, healthy and balanced diet. Several choices of meal are available including vegetarian and diabetic alternatives. Regular meetings are held with residents and in discussion with residents they said that they were consulted and provided input into the planning of activities. A selection of organised activities is provided and relatives spoken with commented that they thought that the home provided appropriate support and encouragement to residents to engage in activities. In discussion with relatives and residents it was clear that people are able to make the their own decisions and lifestyle choices. Several residents access the community independently and the home provides opportunities for residents to attend church services of their choice and services are held regularly in the home. A service took place during the inspector’s visit to the home and many of the residents were observed to attend. The home has it’s own hairdressing salon and a visiting hairdresser was in attendance during the visit. Residents were observed to be free to choose where and how they spent their time. Staff have the opportunity to engage in activities such with residents. One staff member spoke enthusiastically about the weekly cooking group that they held with a number of residents. Staff did comment however that at times due to staffing shortages it became more difficult to spend time with residents. Whitehaven Lodge DS0000039153.V289328.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Satisfactory systems are in place for residents to address any concerns or complaints that they may have and staff receive appropriate training in adult protection procedures. EVIDENCE: At the last inspection the manager was unable to demonstrate that appropriate checks had been made on staff before recruiting them to work at the home. This has now been rectified. The recruitment records of newly appointed staff were examined and evidence was seen that Criminal Records Bureau and Protection of Vulnerable Adults checks had been completed prior to them starting work. This provides residents with greater protection and is an improvement on the findings of the previous inspection. Most residents who completed a questionnaire responded that they knew how to make a complaint if they were unhappy about anything and residents are provided with this information when they move in. Adult protection training is organised for all care staff and the inspector saw from staff training records that refresher training is provided and implemented into the training plan for all staff. Adult protection issues were discussed with staff and they were able to demonstrate that they were aware of reporting procedures. All residents spoken with reported that they felt safe and well looked after by the staff. Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 16 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, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Standards of hygiene are maintained throughout the home. Improvements to the physical environment have been made. However further improvements are necessary to ensure residents comfort and safety. EVIDENCE: During the visit to the home a tour of the premises took place that included all communal areas of the home including bathrooms and toilets, lounges and the dining room as well as several residents’ bedrooms. Several areas were noted as needing attention. In the hairdressing salon it was noticed that the wallpaper was hanging down in places and this appeared to be due to either damp or condensation. In one bedroom it was noted that the bed was very old and would benefit from being replaced. Some residents did remark upon their beds being old and uncomfortable. The home has a garden that is accessible and residents were observed to use this area to take exercise in. However there is a lack of suitable garden of Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 17 garden furniture. Some of the existing garden furniture is broken and unusable. There is also very little seating and this commented on by several residents several. Residents said that they wanted more garden furniture including umbrellas for shade. This was discussed with the manager who agreed that the current provision was insufficient. In discussion with relatives prior to visiting the home some comments were made regarding poor standards of hygiene. However no issues or concerns were raised during the unannounced visit to the home regarding the cleanliness or standard of hygiene and there were not any unpleasant odours. Residents said that their rooms were cleaned regularly and that they did not have any concerns regarding the cleanliness of the home. Infection control procedures were observed to be followed and cleaning staff and a laundry assistant were on duty during inspection. Bathrooms had been re-painted since last inspection. The manager reported that residents had agreed at a meeting to use money from their activities/amenities fund to pay for aesthetic improvements to the bathrooms and toilets such as pictures etc. The manager said that she had to prioritise from her budget other areas of the home that needed attention. This is unacceptable and is the responsibility of the home to provide such items. The inspector was satisfied that requirements from the previous inspection were being addressed in line with the action plan submitted following the last inspection, with several outstanding areas due to be completed by the end of July 2006. The home has suitable adaptations fitted such as grab rails and call bells were fitted in all rooms seen during the visit. Residents reported that staff responded to these appropriately. New fire doors were being fitted to all residents’ bedrooms and this was near completion at the time of the visit to the home. These will be linked to the main fire system. This will greatly improve on safety and means that those residents who prefer their doors to be open can do so safely. At the last inspection a requirement was made regarding the front door being constantly locked, which was restricting those residents who were able to leave the home unescorted. A Keypad system has now been installed on the front door. However currently residents assessed as safe to go out on their own are not given the code so they are still reliant on staff to let them out. The manager said that this was a difficult issue to manage as other residents could leave at the same time. This will need to be risk assessed and consideration will need to be given to enable residents to have access to this code. Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 18 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, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Staff are well trained, caring and helpful. An improvement to the homes’ recruitment procedure offers greater protection to residents. Staffing levels are however compromised and at times staffing levels are not sufficient to meet residents’ needs. EVIDENCE: In discussion with residents they did comment that the home was sometimes short staffed and that cleaners sometimes helped out with breakfast and other duties. Staff also reported that staffing levels were at times compromised. On the second day of the visit the home was short staffed. A minimum of two care staff are needed to be on each floor of the home at any time. However while there were two members of staff in attendance upstairs, there was only one staff member on the ground floor. The manager commented that the fourth staff member was accompanying a resident to a hospital appointment. It was reported that care co-ordinators assist with care however little evidence of this was seen and in addition to this they have administrative and medication administration duties. In discussion with staff it was commented that while care coordinators were expected to assist during staff shortages this did not often happen. Evidence from observation of the medication administration procedures as discussed in standard nine of this report would support the fact that staffing levels are not always sufficient. Further to this the home has Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 19 notified the Commission for Social Care Inspection that they have been short staffed on occasions. Evidence supplied in the pre inspection questionnaire and through discussion with relatives and residents would suggest that the home has a lot of vacancies and relies heavily on the use of agency staff. Residents spoken with commented on the caring attitude of staff. Comments included, “ They are very helpful” and “ All of them are very nice”. Visitors also commented that staff were kind and considerate. The inspector observed there to be a relaxed and friendly atmosphere between the manager, staff and residents. Staff training records were received with the pre-inspection material. Each staff member has undertaken a range of training relevant to their roles and responsibility. A training plan was in place for the current year to ensure that staff receive regular updates in the core areas of training such manual handling, fire, adult protection and first aid Basic. More specific training in areas such as dementia care is also provided. All staff involved with food preparation undertake food hygiene training and COSHH training is provided to all domestic staff. A high proportion of staff have been trained to NVQ level 2 or above with more planned for the current year. A requirement was made at the last inspection regarding poor recruitment practices including lack of Criminal Records Bureau and Protection of Vulnerable Adults checks and incomplete application forms. The records of three recently employed members of staff were examined and it was found that all satisfactory checks had been undertaken and that each staff member had been through a thorough recruitment procedure. This standard has now been met. Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 20 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): 31,33,35,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The manager is accessible and sensitive to the needs of service users. However management procedures need to be introduced to address requirements made at this and previous inspections. The standard of record keeping needs to be improved to ensure that service users’ best interests are safeguarded. EVIDENCE: Several requirements were made at the last inspection and action was being taken to address most of these. This report has highlighted areas that require more attention. The manager submitted a written response to the last report detailing the actions that were being taken to address the issues and the inspector found this to generally reflect the improvements with the exception of care planning. Which showed little evidence that this has been done satisfactorily. Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 21 It was reported that the manager is accessible and approachable to residents and staff. Staff said that they received a good level of support and had regular supervision and appraisals. This was substantiated through examination of staff files. The home was in the process of undertaking resident surveys to seek their views and regular resident meetings take place. However at present there is no system in place to ascertain the views of relatives, representatives or stakeholders and this means that the home is unable to assess whether it is meeting its aims and objectives and to put an improvement plan in place. Generally record keeping is maintained to a satisfactory standard. However the inspector found evidence that on at least one occasion the Commission for Social Care Inspection had not been notified when an incident had occurred at the home. It was also noted that photographs were not available on staff or resident files. Otherwise records were stored correctly, securely and confidentially. Shortfalls in safety identified at the last inspection have been satisfactorily addressed. Inspection of the fire logbook showed that call points and emergency lighting tested weekly and that a monthly check of extinguishers is now carried out. Regular fire drills are also completed. A recent visit by a fire officer had however outlined that a new fire risk assessment was needed and that push bars needed to be fitted to exits. This had not been carried out at the time of this inspection. Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 22 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 2 3 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 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 2 X X X X 2 X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 2 2 Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP4OP7 Regulation 14 & 15 Requirement The registered manager must ensure the plan of care reflects the assessed and reassessed needs of the resident. The previous timescale of 30/04/06 was not met. Further failure to comply with this requirement will result in enforcement action. A care plan must be put in place for the resident identified during the inspection. This must detail the persons care needs and provide staff with sufficient guidance as to the level and method of support that this person requires. It must also highlight any risks to the person and detail how these can be managed. All care plans must be reviewed. They must be more detailed and provide specific support instructions and fully address all assessed and identified needs including the identification of any risks and how these are to be managed. DS0000039153.V289328.R01.S.doc Timescale for action 31/08/06 2 OP7 15 (1) 13 (4) (c) 31/07/06 3 OP7 15 (2) (b) (c) 31/08/06 Whitehaven Lodge Version 5.1 Page 24 4 OP8 13 (4) Care plans must address residents’ physical health support needs. Plans must provide clear guidance as to how these needs are to be met. Written guidance must be produced in respect of any resident prescribed PRN medication. This must be incorporated into their care plan. 31/08/06 5 OP9 13 (2) 31/08/06 6 OP9OP27 13 (2) The registered manager must 31/07/06 ensure that sufficient staff are on duty to make certain that safe and accurate procedures are followed when administering medication. Repairs must be made to the wallpaper in the hairdressing salon. The garden furniture must be repaired or replaced to provide residents with safe and adequate seating facilities. A review of the standard and condition of all service users’ beds must be completed and those requiring replacement must be replaced. The registered manager must ensure that staffing levels are maintained at all times. 31/08/06 7 OP19 23 (2) 8 OP19 23 (2) 31/08/06 9 OP24 16 (2) (c) 30/09/06 10 OP27 18 (1) (a) (b) 31/07/06 11 OP33 24(1))(2)( The registered manager must 3) undertake a quality audit of the service seeking the views of residents, relatives, staff and visiting professionals. A copy of the report must be forward to the Commission for Social Care Inspection. Previous timescale of 30/05/06 not met DS0000039153.V289328.R01.S.doc 30/09/06 Whitehaven Lodge Version 5.1 Page 25 12 OP37 13 OP37 17(1)(a) 17 (2) Schedule 3 and 4 37 A photograph of each service user and staff member must be held on record. The Commission for Social Care Inspection must be notified of any incident in the home, which adversely affects the well-being or safety of any service user. Evidence must be provided that the requirements from the fire officer’s inspection of the home have been completed. 31/08/06 31/07/06 13 OP38 23(4) (a) 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Whitehaven Lodge DS0000039153.V289328.R01.S.doc Version 5.1 Page 26 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. 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