Inspection on 11/01/06 for Willow Lodge

This inspection was carried out on 11th January 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

Willow Lodge 08/07/08

Willow Lodge 14/06/07

Willow Lodge 27/11/06

Willow Lodge 09/05/06

Willow Lodge 11/07/05

Willow Lodge 09/02/05

Willow Lodge 07/07/04

Willow Lodge 04/02/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Willow Lodge Osborne Gardens North Shields Tyne & Wear NE29 9AT Lead Inspector Mrs Irene Bowater Unannounced Inspection 11th January 2006 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 Willow Lodge DS0000028828.V275899.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. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willow Lodge Address Osborne Gardens North Shields Tyne & Wear NE29 9AT 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) 0191 296 4549 0191 296 4570 willow.lodge@fshc.co.uk Cotswold Spa Retirement Hotels Limited (wholly owned subsidiary of Four Seasons Healthcare Ltd) Vacant Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (1) of places Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One place is registered to provide respite care and the person admitted may be in either the PD or OP category. One place is registered to provide respite care for named person under pensionable age. One named service user under pensionable age may be admitted to the home. No further admissions are to take place in this category without prior agreement of CSCI. 11th July 2005 Date of last inspection Brief Description of the Service: Willow Lodge is a purpose built care home with nursing that shares the site with its sister home Willow Court. The home is over two floors and each floor has a selection of en suite bedrooms, lounges and dining rooms. The first floor is accessible via the stairs or a passenger lift. There are a number of specialist bathrooms, shower and toilet facilities close to residents’ rooms and communal areas. The grounds are flat, and are accessible to wheelchair users. Some local amenities are within walking distance and the home is close to the local bus routes. There are car-parking facilities to the front of the home. Willow Lodge provides nursing and social care to older people. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over six hours. The Infection Control Nurse from the Health Protection Agency assisted with the inspection for part of the day. Since the last inspection in July 2005 the home has had six additional visits to monitor the compliance with the many requirements made at that inspection. Letters and other correspondence in relation to the reports and meetings are available at the CSCI office. The Company have responded to all the issues raised and continue to work with CSCI and other Agencies. Over the course of the day a tour of the premises took place and residents and staff were spoken to. Care records and other records were also inspected. What the service does well: What has improved since the last inspection? The home has made many improvements to the environment and care provision since the last inspection and subsequent additional visits. The requirements and recommendations are being actioned and an improvement and refurbishment plan have been provided to CSCi. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 6 Residents who are self funding now are issued with terms and conditions of residency. This sets out the rights and obligations of both the residents and the provider. There has been good improvements to the assessment and care planning processes to ensure residents have all their health and personal care needs met. There is evidence that the staff are working with other agencies to ensure the residents specialist health care needs are promoted. Information about the food provided and choices available are improving. The complaints documentation now shows what the home is doing when there is a concern raised. Staff are receiving training in safe working practices and prevention of abuse. Some progress is being made to recruit suitable care and qualified staff. The home has had a temporary manager in post for approximately 8 weeks and he has addressed several issues regarding good housekeeping and infection control. The difference in the cleanliness and freshness of the home has improved with no major concerns raised by the Infection Control Nurse or the Inspector on the day. A refurbishment and redecoration programme has been implemented and new beds, carpets and linen are being provided. The home is generally more organised and maintained. The company have recruited a new manager who should be in post in January 2006 and a deputy manager has been transferred from another home within the Company. What they could do better: The start date for the new manager is central to the homes continued improvement and development. Once in post she must show appropriate leadership, direction and supervision to all staff to ensure all areas of the care and services continue to improve. Further development of the Service User Guide is needed so that residents and their representatives know what the home is able to offer. Although some improvements have been made to the care plans further work is needed to ensure they are up to date and detailed about all care including nursing care needs. A full review of procedures is needed to ensure safe receipt, recording, storage, administration, and disposal of all medication. The recruitment of staff, including an activities organiser, is needed to ensure a quality of life for all residents living in the home. Further training for staff must be sourced to enable care for the residents needs. All of the staff must continue to work hard to keep the home clean and free from infection. The consultation with residents and their representatives must improve so that they feel all concerns are listened to at all times. The refurbishment and redecoration of the home must continue as agreed. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 7 The in house maintenance and risk assessments must be completed and updated as required. Training in moving and handling, fire and updating of the fire risk assessment must be implemented without further delay. All of the requirements from this report must be actioned within the specified timescales. 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. Willow Lodge DS0000028828.V275899.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 Willow Lodge DS0000028828.V275899.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): 1,2,3 There is insufficient information for prospective residents to be clear about the services the home offers to provide. The rights and obligations of both resident and provider are clearly set out in the terms and conditions of contract. The comprehensive admission assessments ensure the residents care needs will be met. EVIDENCE: The Statement of Purpose and Service User Guide remains incomplete and out of date. There is a welcome pack, which consists of photographs and information in large print. The temporary manager confirmed that this had not been a priority given the other issues in the home. A new manager has been recruited and she will review the documents. The terms and conditions (or contract) are now available for residents who are self funding. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 10 The care plans showed that there were initial admission assessments completed by the care manager and the home. These assessments form the basis of the care planning process. Willow Lodge DS0000028828.V275899.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): 7,8,9,10 Further improvements to the care plans will ensure that staff have sufficient information to satisfactorily meet residents assessed needs. The health needs of residents are currently being met with evidence of interagency working. The practices regarding the safe administration of medicines have the potential to place them at risk. Personal support is currently being offered in such a way the protects and promotes residents rights to privacy and dignity. EVIDENCE: A random selection of care plans were inspected. The nursing staff are currently working hard to review all of the care plans to ensure they are clear and up to date regarding all aspects of health, social and personal care. The care plans showed that improvements are being made in regard to completing risk assessments for dependency, nutrition, pressure sores, continence and assessments for the use of bed rails. There was evidence that residents and relatives are involved in the care planning with care plan agreements signed. Care plans also make reference regarding preferences for female carers. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 12 All residents have access to NHS facilities. Specialist advice is now sought when residents have lost weight or have pressure damage. The care planning records for wound care and pressure sore prevention was clear and up to date. Food and drink charts are available. These records are still not being completed in detail. The residents were appropriately dressed and those who were poorly in bed were clean, comfortable and had fresh bed linen. The timing of the medicine rounds has improved. The medicines were dispensed at suitable times during the day. The Medicine Administration Records showed no gaps in recording. The handwritten transcriptions were abbreviated and did not have two signatures. A random audit of the controlled drugs was satisfactory. The home does not maintain record books of medicines received or returned to the pharmacy and currently does not have an appropriate waste management agreement. The treatment room was generally disorganised and untidy. The staff were observed to knock on doors before entering, use residents preferred names and carry out personal care in private. Willow Lodge DS0000028828.V275899.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): 12,13,14,15 Social activities do not provide stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with opportunities to maintain their previous lifestyles. The staff support residents to maintain choices and control as far as they are able. The home provides a varied menu with choices available. Further development of this service is needed to ensure all dietary needs of residents are recorded. EVIDENCE: The home has been without an activities organiser for some time. There was little evidence to show how or when any meaningful activity takes place on a daily basis. The main event on the day of inspection was a visit from the Optician. The staff still have limited time to spend with residents who are confined to bed because of their health needs. Relatives and other visitors are welcome at any time and they can visit in the communal areas or in the resident’s rooms. Improvements are taking place regarding the staff encouraging residents to maintain choices and control over their daily lives. One resident and his relative are pleased that, at last, the request for another room was agreed. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 14 Despite the daily menu being displayed in the dining rooms and information about weekly menus and alternative choices being available residents still do not know what the menu will be on a given day. It was confirmed that the menus are frequently changed and records of individual choices for each meal are not kept. The lunchtime meal was hot, of ample portion size and well presented. Residents said the “food is nice” and “I get what I want”. There were choices for both the main course and dessert. Other choices were provided and there were some variances to the set menu, which are not recorded. The chef was able to discuss how to provide fortified drinks and how they provided specialist diets. Hot and cold drinks were offered midmorning and at lunchtime. All of the thermos flasks were ingrained with tea stains around the spout and lids. Willow Lodge DS0000028828.V275899.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): 16,18 The complaints procedure is clear, however relatives and residents are not confident that their views are always listened to or acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: There are comprehensive policies and procedures available for residents and their representatives to use should they have any complaints about the care or other services. The Commission for Social Care Inspection have investigated six complaints made by relatives on behalf of residents. In house complaints have been dealt with appropriately with details of investigation, action and outcomes recorded. The home has been without a manager or any senior staff since April 2005 and residents and relatives are still not sure who to speak to should they have a complaint. There are policies and procedures available for the Protection of Vulnerable Adults. There have been two separate multi agency Protection of Vulnerable Adult meetings since July 2005.All of the appropriate procedures were followed by the home to protect the residents. Willow Lodge DS0000028828.V275899.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): 19,20,21,22,24,26 There has been some investment in the home, which is improving the environment for residents living there. There are a number of outstanding requirements, which have the potential to place residents at risk. There are infection control and health and safety issues, which place residents’ staff and visitors at risk of harm. EVIDENCE: The location and layout of the home is suitable for the residents’ current needs. All areas of the home are accessible to residents with disabilities and those who use wheelchairs. Since the last inspection and subsequent additional visits the home has made improvements to all areas and a programme of redecoration and refurbishment is in place. There is evidence of regular cleaning and replacement of furniture and fittings throughout the home and redecoration is ongoing. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 17 There are lounges and dining rooms on each floor. These were clean tidy and suitably furnished. The requirements from the last inspection regarding the cleanliness of the communal areas have been actioned, however there was old food debris and stains on the dining room chairs. The carpet in the smoking lounge has numerous cigarette burns and is stained. All of the bedrooms have an en-suite toilet and hand washbasin and there are bathrooms, showers and toilets close to all bedrooms and communal areas. Improvements again have been made regarding the cleanliness and maintenance however the following was found on this inspection: The flooring in bathroom 2 remains grimy with mould and soap debris The shower attachment is broken. The extractor fans were dusty and noisy. The assisted bath chair had not been cleaned and had mould and grim on the back. There was considerable water damage to the ceiling in bathroom 3. Bathroom 6 the enamel is missing off the rim of the bath. The flooring in bathroom 5 is damaged and worn There remains a problem with drips from the soap dispensers causing damage to the decoration and boxing to the pipes. Many of the bins do not have foot-operated lids and some of the lids from the swing bins were missing. There is sufficient specialist equipment including hoists, airflow mattresses, assisted bathrooms and toilets to meet residents’ current needs. Grab rails are in all corridors and resident areas where needed .The call system is accessible and is provided in every room. All of the bedrooms are for single occupancy. The housekeeping is improving in these areas with bedrooms being clean and free from odours. There is an ongoing replacement of beds, mattresses and bed linen. Many of the residents have brought small items of furniture and furnishings with them making their rooms individualised and homely. On the day of inspection the home was generally clean, tidy and free from any odour. The infection control nurse from the Health Protection Agency assisted with this part of the inspection and was satisfied that improvements continue to be made. The laundry is separate from resident areas and was organised and clean. The staff have some knowledge of infection control procedures and changes have been made in how all soiled laundry is stored and taken to the laundry. Once in the laundry all linen is then sorted for the appropriate washing cycle. It is then that there is a risk of cross contamination as the laundry is left on the floor. There are sluices on both floors, which are now clean tidy and locked when not in use. On the day of inspection both disinfectors were out of use. All of the storage areas are clean and organised. It was confirmed that Alco gel and paper towels were to be provided in the dining areas and for staff to use should they be unable to wash their hands effectively. Willow Lodge DS0000028828.V275899.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): 27,28,29,30 The lack of a consistent, fully trained staff team has had a detrimental impact on the quality of care provision in the home. The systems for recruitment and selection of staff ensure residents are protected. EVIDENCE: The home has experienced staffing problems throughout the year. No registered manager has been in post since April 2005. A temporary manager has been in the home for approximately 8 weeks. A manager has been recruited and she should commence employment in January 2006.A deputy manager has been in post for approximately 4 weeks. Care and ancillary staffing remain problematic due to staff sickness and staff turnover. The temporary manager has had some success with employing staff, however the staff are inexperienced and agency staff are still used. There have been several occasions when the home has been short of the necessary numbers of care staff to meet the residents’ personal care needs. The temporary manager has always informed the Commission of the shortfalls and deployed staff at alternative times. The current staffing levels for the number of residents currently living in the home are: 2 qualified nurses from 8am to 8pm 7 care staff from 8am to 2pm Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 19 6 care staff from 2pm to 8pm 2 qualified nurses from 8pm to 8am 3 care staff from 8pm to 8am For 2 nights a week there is 1 qualified nurse and 4 care staff. There are now adequate domestic and laundry staff employed over a 7-day period. There is one chef and one kitchen assistant throughout the day and an administrator and maintenance person is employed. A sample of personal files showed evidence of two references, Criminal Record Bureau checks, proof of identity and medical health checks. The temporary manager confirmed that an internal audit of records was being undertaken. New staff spoken to confirmed that they have received induction training. Other staff said that training was ongoing. Training has included, infection control, Protection of Vulnerable Adults, Health and Safety, food hygiene, customer care and 1st Aid. Moving and handling and fire training are not up to date. All of the training records were difficult to follow and were not up to date. NVQ training has been put on hold and should recommence in the near future. Willow Lodge DS0000028828.V275899.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): 31,32,33,35,36,38 The temporary manager gave support, guidance and direction to the home and the staff to enable some consistency in the care and service provision. The systems for consultation and quality monitoring are poor with little evidence to support the resident and representative views are sought or acted upon. Further improvements in the residents personal accounts are needed to ensure all their best interests are protected. There are health and safety practices, which pose potential risks to residents, staff and visitors. EVIDENCE: The home has been without a permanent registered manager for some considerable time. A temporary manager is currently in post until the new manager can start in January 2006. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 21 The temporary manager has tried very hard to begin to address the many issues the home has in terms of care practices, organisational and service provision. Some progress with the environmental, care practices, staffing and customer care has been made. There has been no stability or senior staff in post for some time and the home has suffered from lack of direction and day-to-day organisation. This has impacted all aspects of the service. Information about how the residents and their representatives are involved in the home is not available. None of the meetings have been recorded and there is only limited evidence to support that their views have been taken into account. The Regional Manager for the home has kept the Commission informed about the management issues in the home. There is a central non-interest bearing account for dealing with residents’ personal allowances. Residents’ personal allowances are held in a central noninterest bearing account. The Company is planning to change the systems to enable residents accrue interest on their own money, however this has not occurred to date. The home maintains detailed records of all transactions with cross-referenced receipts. There has not been an internal audit for some time and all transactions do not have two signatures. Formal supervision for staff has not been undertaken for some time. The content of previous documentation was good. None of the staff have had an appraisal. Staff have received training in safe working practices, however moving and handling and fire training are not up to date. The fire assessment for the home has not been reviewed, updated or signed for the current year. In house maintenance checks and risk assessments have not been completed since November 2005. All utility contracts were available and up to date. Storerooms were locked and chemicals were safely stored. Risk assessments for the safe use of bedrails were completed in detail. Accident recording and reporting is now satisfactory. One of the hot trolleys was not keeping the food at the appropriate temperature. Willow Lodge DS0000028828.V275899.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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 1 3 X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 2 2 X 2 Willow Lodge DS0000028828.V275899.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 OP1 Regulation 5 Requirement The Service User Guide must be reviewed and updated. Timescale of 01/11/05 not met The home must review all of the care plans to ensure they are up to date, set out the action to be taken in regard to health, personal and social care needs. Timescale of 01/11/05 not met. The home must ensure that all handwritten transcriptions are written in full and have two signatures. A record of all medicines received, leaving or disposed of must be kept to ensure there is no mishandling. Suitable waste management procedures must be in place and the organisation and storage systems improved. The home must consult with residents about their social interests and make arrangements for them to engage in activities both inside and out of the home, which suit their needs, preferences and DS0000028828.V275899.R01.S.doc Timescale for action 31/03/06 2 OP7 13,15 31/03/06 3 OP9 13,17 31/03/06 4 OP12 4,12,16 31/03/06 Willow Lodge Version 5.1 Page 24 5 OP12 4,12,16 6 OP15 13,14,15 7 8 9 OP20 OP20 OP21 23 23 23 10 OP24 16,23 capacities. Up to date information about activities must be circulated and social interests recorded. The home must ensure that particular attention is given to providing activities for residents with cognitive impairments and for those who are confined to bed. Timescale of 01/10/05 not met. The home must ensure that all resident’s choices for meals are recorded on a daily basis. Any changes or additional to the menu choices must also be recorded. The thermos flasks must be replaced. The home must replace the damaged smoking room carpet. The home must ensure that the dining room chairs are cleaned after use. The home must replace the flooring in the shower rooms. The shower attachment must be replaced or repaired. All of the extractor fans must be cleaned. The water damage to the ceiling must be repaired. The assisted bath chair requires cleaning and the enamel repaired. The shower chair requires cleaning. A review of the position of soap dispensers and how soap spillage is managed is required. All bathrooms, shower rooms and toilets require bins with suitable lids. Timescale of 01/11/05 not met The home must continue with replacement of bedroom carpets, DS0000028828.V275899.R01.S.doc 31/03/06 31/03/06 01/06/06 31/03/06 30/06/06 30/06/06 Page 25 Willow Lodge Version 5.1 11 OP26 12,13,16, 23 12,13,16, 23 12 OP26 13 OP27 18 14 OP28 18 15 OP31 9 16 OP33 24 17 OP35 17,20 18 OP36 18 19 OP38 23 beds and linen. The home must ensure that both sluice disinfectors are working. Timescale of 30/09/05 not met. The home must ensure that soiled linen and clothing is not stored on the floor prior to being washed. Suitable containers must be provided. The home must ensure that at all times suitably qualified, competent and experienced staff are working at the home in such numbers as are appropriate for the health and welfare of the residents. The home must recommence NVQ level 2 or equivalent training for care staff. Timescale of 31/03/05 not met There must be a suitably qualified 1st Level Registered Nurse employed to manage the home. The home must establish a system of reviewing the quality of all care provision in the home and develop systems for consultation with residents and their representatives with records kept. Resident surveys must be published and made available to all interested parties. The home must ensure that any interest accrued on residents money is paid into their individual account. All entries require 2 signatures. The home must continue with formal supervision for staff. Timescale of 01/11/05 not met. The home must ensure that all staff receives the required fire training of twice a year for day staff and four times a year for DS0000028828.V275899.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 01/09/06 31/03/06 31/03/06 31/03/06 Willow Lodge Version 5.1 Page 26 20 OP38 23 night staff with detailed records kept. All staff must receive up to date training in moving and handling. Timescale of 11/10/05 not met. The home must ensure that all in 31/03/06 house maintenance checks and risk assessments are up to date and signed. The thermostat on the hot trolley must be repaired. 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 Refer to Standard OP26 Good Practice Recommendations It is highly recommended that the recommendations of the Health Protections Infection Control Audit are progressed and further training sourced. Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Willow Lodge DS0000028828.V275899.R01.S.doc Version 5.1 Page 28 - 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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