Inspection on 22/09/05 for Whitehaven Lodge

This inspection was carried out on 22nd September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 16/02/06

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 Unannounced Inspection 22nd September 2005 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 Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 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.V249996.R01.S.doc Version 5.0 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.V249996.R01.S.doc Version 5.0 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. 03/02/05 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.V249996.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced visit to the home since April 2005. The purpose of the visit was to review the outcomes of the requirements made during the previous visit in February 2005 and assess some of the core standards the home has to comply with. The manager was on a course on the day of the visit so the duty care coordinator and some of her colleagues assisted the inspector with the inspection. Following the outcome of the visit two immediate requirements were issued in respect of fire doors on bedrooms being held open inappropriately and holes and bolts left in the floors following the removal of fire water hoses six weeks previously. The home has been issued with sixteen requirements following this inspection of the sixteen requirements issued two have been repeated for the third time and one has been repeated for the second time. A decision will be made if enforcement action will be taken. What the service does well: What has improved since the last inspection? There has been very little improvement since the previous visit to the home. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 6 The homes complaint procedure now has the correct name of the regulatory body should residents or their representatives wish to make a complaint about the home. Some of the residents have had new carpets and bedroom furniture and an area of the home has been renovated to provide extra three bedrooms with on suite facilities. What they could do better: 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. Ensure staff are 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 ensure residents are made fully aware of their rights whilst living in the home, the home must ensure the residents are issued with the revised statement of terms and conditions of residency and following consultation with the resident provide them with a copy of their personal plan if they wish. 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 service has done little to protect the residents from abuse or risk of environmental harm. Therefore the service must insist a full investigation into the theft of resident’s money and personal belongings is undertaken and the service/organisation must ensure it consults with the Hampshire Fire and Rescue to ensure that it is fully complying with fire regulations. The home must also ensure that it considers the health and safety of its staff by promptly dealing with maintenance issues that can cause harm and subsequently have an adverse affect on the health and welfare of the residents. The home could do better to provide an environment that is comfortable, clean, and free from offensive odours and aesthetically pleasing. The home has been issued on two 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 and take what ever action necessary to eradicate smells form carpets. To date this has not been actioned, therefore another requirement has been issued and a decision will be made to consider enforcement action. In addition the home must ensure particular attention is made to the cleaning of bathrooms and toilets where there is potential risk of cross infection. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 7 The home could do better to ensure that there are at all times enough skilled staff in such numbers to meet the health and welfare needs of the residents. 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.V249996.R01.S.doc Version 5.0 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.V249996.R01.S.doc Version 5.0 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 and 3 The home ensures it can appropriately support and meet the needs of prospectus resident by undertaking a thorough assessment prior to moving into the home. The home issues residents with terms and conditions of residency, however further work is required to ensure the residents receive the revised and up to date version. EVIDENCE: The inspector viewed four residents’ assessment information, these related to some residents who had lived in the home for a number of years and one who had recently moved into the service. There was evidence to suggest the home has undertaken an assessment process to identify the areas of strength and need of the resident. In addition to the homes assessment process the home obtains assessment information from Social Services. The senior staff member on duty informed the inspector that a care coordinator or the manager will meet with the prospective resident and their relatives or representative prior to being admitted to the home. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 10 For those residents who had been living in the home for a number of years there was evidence that their needs are reviewed with them regularly using a “Bartel” assessment process, this assists the home to monitor residents’ strengths and needs. However the inspector overall finding of the assessment information was: 1. Not all information had been completed i.e. personal history/pen picture. 2. Not all information provided in the Social Services assessment had been transferred or picked up in the homes assessment. 3. Not all residents “Bartel assessments had been completed on a regular basis. The home ensures residents are issued with terms and conditions of residency, however only one of the four residents contracts viewed by the inspector had Southampton City Councils’ revised version, which includes date the resident was admitted to the home, the fee to be paid, the room to be occupied by the resident and evidence of the resident signing the contract. The three further contracts viewed by the inspector had not been completed properly and did not state fee, room number or in all cases evidence of the residents signing. Therefore the home cannot evidence that it has made all the residents or their representatives aware of their rights and their terms and conditions of residency. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 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 and 10 The home attempts to meet the residents’ health and welfare needs in a respectful and dignified manner, however there is evidence to suggest further work is required by the home to improve the standard of care they are providing. EVIDENCE: The inspector viewed four residents’ personal plans, which provide information on the residents DOB, NOK, GP and Social Worker etc.. files contain the residents’ assessment documentation, care plans, risk assessments, contract details and correspondence. In addition each resident has a task plan, which is a summary of the care plan and informs the staff what assistance the residents requires. However the overall view of the care planning process based on the evidence found on the day of the visit is that staff are unable to provide a consistency of care and know all the areas of need for the residents because of the following factors. 1. Not all assessments had been fully completed. (Standard 3) Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 12 2. Not all care plans fully reflected the areas of care required as identified in the assessment. i.e. needs assistance to dress lower body and drink plenty, (no evidence of need in care plan). 3. Not all care plans had been completed to provide specific information on how the resident wishes to have their care carried out. The inspector found only one of the four residents’ plans viewed to give detailed information on how a specific area of care was to be carried out. 4. Risk assessments covered general themes as required following previous visits to the home i.e. leaving the home, drinking alcohol, but did not cover specific risks as identified in the assessment i.e. the resident has a history of falls. 5. The personal files were in a muddle and information could not be located easily within the file. 6. One resident’s information had not been updated since using the home for respite and then being admitted to the home, despite this occurring over a year previuosly. 7. Task plans used daily by staff could not be located in the home. The inspector was informed that the home has recently taken the decision to remove task plans from residents’ rooms to a central area as some residents would remove or tamper with the plans and these were currently under review by the senior care coordinator who has recently been seconded to another Southampton City Council Home. The staff with whom the inspector discussed the plans with could not provide evidence that consultation had taken place with the residents with regards to the homes decision to hold plans centrally. Therefore the home cannot evidence in all areas that it consults and respects decisions made by the resident. The home must consult where possible with all residents and provide those residents wishing to hold their task plans, are provided with a copy that is regularly reviewed with them and updated as required. This will be reviewed during the next visit to the home. 8. The inspector could not establish which file was for what as there was duplicated information and information located in various files and in various offices. A hand over is held at each shift, however the home relies heavily on agency staff and on occasions there are not suffient numbers of staff to fully meet the needs of the residents or provide full details at handovers. This was further evidenced by an agency staff member coming on duty flustered because she had been asked to come in earlier and cursed and swore because there were Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 13 no staff around to tell her where she was working and who she was working with. The inspector was informed that she is a good agency worker. The home must therefore ensure records held on residents provide clear and accurate information at all times. These must detail how the resident wishes to be supported, risk assessments must be individualised to reflect the specific area of risk, a copy held by the resident if they wish, and easily accessible to all carers to ensure a consistency of care is provided. The home does ensure the health care needs of the residents are met and take appropriate action to ensure the residents’ receive visits by their GP when required, receive regular checks by the dentist, opticians and chiropodist and receive specialist input from specialist health care services such as physiotherapists and community psychiatric nurses when required. This is further demonstrated by the appropriate recorded actions received in the office of the Commission for Social Care Inspection when the health and welfare of residents has been affected. Medication policies and procedures were not fully assessed on this occasion, however the home has met the requirement issued at the previous inspection to develop care plans where residents receive as required medications. The senior responsible for completing the plans stated she had consulted with GP’s and the residents before completing the plans. However the manager must ensure medication administration recording sheets are adjusted where possible by the GP or pharmacist to reflect GP’s requests, i.e. “As required” now being used as a regular medications. The inspector was also informed that the home is in the process of changing its medication administration system with a reputable pharmacist who will provide additional support in terms of training and medication queries. The home attempts to meet residents’ needs with respect and dignity and staff were observed adopting a respectful approach to the residents when conversing with them, however in view of the homes decision to remove the tasks plans from the residents rooms and a very personal conversation overheard in the entrance to the home with a carer and a relative of a resident who was also present does not demonstrate that the home fully respects the rights, dignity and privacy of the residents. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were not fully assessed on this occasion, however these will be fully reviewed during the next visit to the home. EVIDENCE: The inspector spoke briefly with a small number of residents who said that living at Whitehaven Lodge was okay and the staff are very nice. The monthly quality report sent to the Commission for Social Care Inspection (regulation 26), received on a regular basis provides information on the residents’ views of the service and activities undertaken in the home. The latest report indicated that some residents had taken part in regular bingo sessions, an art and weekly cooking sessions. In addition the report indicated that the home was organising a boat trip and an outside entertainer holds regular music sessions. However one of the member of staff on duty at the time of the visit stated she felt she didn’t always have enough time to spend quality time with the residents and on one occasion had left it to agency staff to organise the bingo session. This demonstrates that staff are dedicated, passionate and are concerned about the quality of care they are able to provide when staffing resources are limited. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 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 The home has now improved the information it provides to residents and residents’ relatives on how to express their views and their concerns. The home has taken steps to ensure staff are aware of their roles and responsibilities in safeguarding the residents from potential risk of harm, however the home must ensure it investigates thoroughly all incidents of alleged abuse. EVIDENCE: Previous visits to the home identified that the information provided to the residents and residents representatives on how to make a complaint provided incorrect information with regards to the regulatory body who inspect the home. The error has since been corrected and residents and residents representatives are issued with a Health and Community Care Guide which includes a service user guide, statement of purpose and a leaflet on “Your Views Count”, this includes a complaints procedure which clearly details who will deal with the complaint. A recent complaint picked up during a monthly visit to the home by a representative of Southampton City Council, identified that not all the residents were happy when the stand-in cook cooks chicken curry, there is evidence to suggest that thus was later addressed through a residents meeting where residents were asked to provide further details on how they would like the curry. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 16 This demonstrates that the home addresses concerns and complaints made by the residents. The inspector spoke with a senior member of staff who clearly detailed her roles and responsibilities in reporting and dealing with allegations of abuse. The member of staff’s response was in line with the services adult protection policy. However the inspector has received a number of reports (regulation 37 notice) spanning from April 2005 reporting theft of money, jewellery from residents and groceries from staff. The home is able to evidence that it has contacted all the appropriate authorities including the police who state because of the number of people accessing the service. Working, visiting, and living in the home it would be difficult to establish who the perpetrator is. The home can evidence that it has spoken with residents and advised them of keeping their belonging safe, spoken with staff about keeping personal belongings safe and what action would be taken if it were discovered that one of them was the perpetrator. However another recent theft in the home of which the inspector was notified at the time of the visit needs thoroughly investigating and the organisation must ensure appropriate action is taken to protect the residents at all times. Staff with whom the inspector spoke with said that it had left an uneasy feeling in the home and that they didn’t know whom they could trust. An uneasy team leads to a demoralised team, which will in turn affect the wellbeing of the residents. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 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): 19,23 and 26 The home has made some improvements to some of the residents own rooms, however further significant improvements need to be made to provide a safe, well maintained and pleasant environment for residents to live in. Please refer to standard 38 regarding residents’ safety. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 18 EVIDENCE: The home is large and purpose built for older people who can no longer be safely supported in their own homes. There is one large kitchen and a separate laundry room, both have their own designated staff team. These areas are not accessible to service users unless closely supervised by staff. The inspector was informed that recently a serious accident had occurred in the kitchen where a member of the kitchen staff tripped on raised flooring caused by continuous water seeping up from the drain. The incident resulted in a serious injury to the staff member. The member of staff has since been off work and an agency cook has taken their place, the home has recently received complaints from residents regarding the standard of food. The staff could confirm that numerous calls had been made to the maintenance department requesting them to rectify the problem. This area was viewed by the inspector who found the affected areas to be covered with a mat, which had become wet by water seeping up through the raised and broken flooring. This is a serious health hazard to both staff and residents and must be addressed without delay. The home has a large walled garden, which is comfortably arranged to support service users to wander unaided, and a separate sensory area with raised beds and heavily scented shrubs. A Gazebo and plenty of seating provides shade and places to sit in the warmer months. The inspector met with a number of residents and viewed their bedrooms. The residents with whom the inspector spoke with said they liked their rooms and they had been able to bring in some of their own furniture which made them feel a little more at home. The bedrooms that the inspector viewed at the time of the visit were clean, tidy and personalised with the residents’ own belongings. Staff informed the inspector that some residents had new carpeting and furniture in their rooms. Two residents with whom the inspector met with proudly showed off their new bedroom furniture and carpeting. However the requirements issued following the previous visit to provide the Commission for Social Care Inspection with an action plan and timescales to: 1. Upgrade and redecorate the breezeblock interior 2. Make aesthetic improvements to the bathrooms and toilets 3. Replace carpets. This requirement has now been repeated on three occasions. A decision will be made whether further legal action will be taken by CSCI staff. Staff confirmed that the areas identified previously had been viewed by senior managers on several occasions and discussions had taken place with the home manager but Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 19 they were unsure what decision had been made or when the works were to be carried out. The manager was also required to take whatever action she could to eliminate unpleasant odours coming from the carpets. This requirement has now been repeated on three occasions. A decision will be made if further legal action will be taken. At the time of this visit the inspector could clearly detect an unpleasant odour on entering the building. The inspector found the home to be generally clean and tidy however the manager must ensure attention to detail is undertaken when cleaning bathroom and toilets. The inspector found grimy plugholes, clogged up with soap and hair razor blades, and hoist seats were very dirty underneath. These areas if not cleaned to a very high standard could result in residents becoming unwell and could potentially cause a spread of infection. Therefore the manager must ensure domestic staff pay particular attention to these areas when cleaning. Other areas of serious concern regarding the environment have been addressed in standard 38 of this report. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 20 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 The home tries to meet the health and welfare needs of the residents by having adequate numbers of staff on duty, however this is compromised by staff vacancies. Standard 29 was not assessed on this occasion, as the inspector could not gain access to staff records. EVIDENCE: On the day of the visit to the home the inspector established that the home was short staffed and had been relying on agency staff on a regular basis to cover shifts. The senior member of staff on duty appeared very rushed and flustered there had only been three carers and two care coordinators on duty for forty-seven residents, the inspector was informed that this was down to vacancies and short notice absence. The duty care coordinator could demonstrate that she had tried to cover the shifts but stated this was a regular occurrence. As described earlier in the report an agency staff member had arrived on shift early as requested and appeared very annoyed that there was no one around to tell her where she was working. The agency member of staff was heard cursing and swearing. Later another member of senior staff stated she felt awful on one occasion when it was her and just agency staff and two new residents were being Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 21 admitted to the service, she stated she felt awful because she couldn’t give them the time she should have to make sure they had settled into the home properly, had all the information and paper work explained to them and were provided with a key to their room. Subsequently one of these newly admitted residents has had money stolen from them. In view of lack of information found in residents’ personal files, the lack of an appropriate induction into the home and the regular dependency of agency staff places the residents at risk of not having their health and welfare needs appropriately met. Therefore the manager must reassess dependency levels of all residents currently living in the home, adjust staffing level to meet the dependency need and refrain from admitting new residents to the service until such time staffing levels adequately meet the needs of the residents. The inspector was unable to access staffing records as the manager was not available at the time of the visit, however these records will be thoroughly reviewed during the next visit to the home. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 22 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): 38 The home does not provide a safe environment for residents to live. EVIDENCE: Following a tour of the building the inspector established that the home does not protect and safeguard the residents from the potential harm of fire or injury caused by shoddy workmanship. Two immediate requirements were issued at the time of the visit in respect of fire door closures on bedroom doors and holes and bolts protruding from the floor where fire hoses had been removed. The holes and the bolts were located in corridors where residents regularly walk. The inspector was made aware that the residents’ bedrooms doors had been without appropriate closures for thirteen months and the holes in the floor for approximately six weeks. A letter later seen in the fire logbook confirmed that the residents had been notified in August 2004 of the removal of fire door guards. The inspector observed that a number of residents had obtained door wedges or were using furniture to hold their door open, furniture was also used by staff to hold a Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 23 bedroom door open when escorting the resident out of their bedroom. The inspector spoke with a small number of residents who stated they didn’t like the door shut because they liked to see and hear what is going on and they felt shut away if the door was closed, one resident said “its like being in a concentration camp with the door closed”. Residents were observed to become upset when they were informed they would have to shut their doors. A resident stated it had been like that for a year and something was supposed to be done about it. The home must take immediate action to remove bolts and cover holes in floors to prevent risk of harm from falling and following consultation with the Hampshire Fire and rescue fit appropriate closures to the residents bedroom doors to prevent the potential risk of fatalities from smoke inhalation and fire. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 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 2 X X 2 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 X X X 3 X X 1 STAFFING Standard No Score 27 1 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 1 Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 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 OP2 Regulation 14 Requirement The registered manager must ensure the staff responsible for assessing new prospective residents thoroughly complete the assessment documentation. The registered manager must ensure all residents are issued with the revised statement of terms and conditions. (Contract of Residency). ensuring it clearly states the date of admission, the fee, the room to be occupied and is signed by the residents or residents’ representative. The registered manager must ensure records held for residents provide clear and accurate information, detailing “how” the resident wishes to be supported. This requirement has been repeated. A further failure to comply will result in further action being taken. Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 26 Timescale for action 31/10/05 2 OP5 5 30/11/05 3 OP7 12(2) 15(1)(2) 30/11/05 4 OP7 13 The registered manager must ensure risk assessments reflect the individualised and specific area of risk. i.e. Risk of falls. The registered manager must ensure recorded consultation takes place with each resident to establish if they wish to hold their personal plans. The registered manager must ensure all staff are aware of the values of dignity and privacy. Where necessary training must be provided. Relatives must be encouraged to talk about personal details pertaining to their relative in private. 30/11/05 5 OP7OP10O P17 12 30/11/05 6 OP10 12 31/10/05 7 OP18 13(6) 30/10/05 The registered manager must ensure that all allegations of abuse are thoroughly investigated through the Protection of Vulnerable Adults. The responsible individual must ensure that appropriate action is taken by all authorities to establish who the perpetrator is and make safe the residents. 8 OP19OP21 OP24 23 23(2)(d) The registered manager must provide the Commission for Social Care Inspection a schedule of works that identifies actions and times scales to upgrade and redecorate: • • The breezeblock interior. The bathroom and toilets. 30/10/05 Whitehaven Lodge DS0000039153.V249996.R01.S.doc Version 5.0 Page 27 • The carpets. This requirement has been issued for the third occasion. A decision will be made to consider enforcement action. 9 OP24OP26 16(2)(k) 23 The registered manager must take whatever action she considers necessary to ensure there are no adverse odours from the flooring. This requirement has been issued for the third occasion. A decision will be made to consider enforcement action. The registered manager must ensure the kitchen floor is repaired and made safe. In the interim the registered manager must undertake a risk assessment of all staff accessing the kitchen. 11 OP15OP19 16(2)(i) 37(1)(e) The Registered manager must notify the Commission for Social Care Inspection under regulation 37 when the work to the kitchen floor takes place with the contingency plan for providing and preparing meals for the residents. The registered manager must ensure attention to detail is undertaken when cleaning bathrooms, bathroom equipment and toilets to prevent the potential risk of infection. The registered manager must reassess all the residents’ dependency levels and adjust the staffing establishment to DS0000039153.V249996.R01.S.doc 30/10/05 10 OP7OP19O P38 23(2) 13(4) 30/10/05 30/10/05 12 OP19OP26 16(2)(j) 23(2)(d) 30/10/05 13 OP3OP27 18(1)(a) 04/11/05 Whitehaven Lodge Version 5.0 Page 28 meet the level of need to ensure the residents health and welfare needs are appropriately met at all times. 14 OP3OP27 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. The registered manager must ensure the holes and bolts left following the removal of fire hoses are filled in or removed. The registered manager must seek advice form the Hampshire Fire and Rescue service on the appropriate closures for resident’s fire doors and fit by the stated timescale. 04/10/05 15 OP38 23(2) 13(4) 30/09/05 16 OP38 23(4) 13(4) 30/09/05 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.V249996.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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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