Inspection on 11/07/05 for Willow Lodge

This inspection was carried out on 11th July 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 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 11/01/06

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 Irene Bowater Unannounced 7 July 2005 9.30am & 22 July 2005 7.00am th nd 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 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 B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willow Lodge Care Home Address Osborne Gardens North Shields Tyne & Wear NE29 9AT 0191 296 4549 0191 296 6550 willow.lodge@fshc.co.uk Cotswold Spa Retirement Hotels Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant CRH 48 Category(ies) of OP Old age (47) registration, with number PD Physical disability (1) of places Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 One place is registered to provide respite care and the person admitted may be in either the PD or OP category. 2 Should the named service user in the PD category leave the home the Commission for Social Care Inspection must be notified immediately. Date of last inspection 9th February 2005 Brief Description of the Service: Willow Lodge is a purpose built care home with nursing that shares the site with it sister home Willow Court. The home is over two floors and each floor has a selection of ensuite 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, include a pleasant seating area to the front of the home 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. One permanent resident is below pension age and there is an agreement for an intermittent admission of another person below pension age on a respite basis. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two separate days at different times. This was because of serious concerns, which were found on the first day, and which resulted in the inspection being stopped, in order for the home and company to take immediate action. The company responded in writing to the immediate requirements issued within the agreed timescales. Given the serious concerns raised at the first visit, the Health Protection Agency was requested to carry out an infection control audit of the home and this report has been shared with the home. A further unannounced visit took place to complete the inspection and to ensure the appropriate action was being implemented by the home. The inspections upheld a complaint regarding a resident’s care in the home and began a Protection of Vulnerable Adults Strategy Multi Agency process, which is still ongoing at the time of reporting. Letters and other correspondence in relation to the meetings are available at the CSCI office. Over the two visits tours of the premises took place, residents and staff were spoken with on both occasions. Care records and other records were inspected on both days. During the two visits to the home fifteen residents and seventeen staff were spoken with. Discussions were also held with the company representatives for the home on both occasions. What the service does well: The residents said that the staff were nice and they worked hard to improve things for them in the home. The residents were appreciative of the effort made arranging entertainment and outings for them. The recruitment of staff follows thorough procedures in order to protect the Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 6 residents living in the home. What has improved since the last inspection? What they could do better: The home is without an experienced manager and this has affected the care and services provided for the residents. Residents’ personal and health care needs are being neglected due to lack of trained, competent, sufficient staff to care for their assessed needs. The company representatives must make sure that the serious concerns set in the immediate requirements and in the requirements recorded in the report are put right within timescales to ensure that the care, safety and life experiences of all residents improves to an acceptable standard. The service user guide still has not been updated and residents who are self funding still do not have a contract. Assessment and care that residents receive needs to improve to ensure the staff know what to do for each resident. The nurses need to ensure that all residents health care needs are recorded and any specialist nurse advice followed. The nurses need to follow requirements for the safe administration of medicines. The social and leisure care of the more poorly residents needs to improve to enable them to have a quality of life within the home. Complaints and concerns from residents and relatives need to be properly looked into and suitable action taken to resolve and improve the home. All staff need to complete specialist and other training to make sure all residents needs are met and they are protected from harm. The staff must follow infection control and good housekeeping procedures to prevent risk of infection and to make sure all areas of the home are always clean well maintained and free from unpleasant smells. There needs to be enough staff of all grades in the home to meet residents needs at all time and the staff need to be given appropriate direction and supervision. The home must ensure that all risk assessments are carried out to ensure the safety of residents living in the home. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 7 A refurbishment replacement and redecoration programme needs to be introduced to show how all the maintenance problems are going to be managed. All the health and safety issues, which have been identified, must be actioned to ensure the health, welfare and safety of all residents, staff and other visitors to the home. The recruitment of an experienced manager who will lead, direct and supervise the staff and manage the home appropriately is essential to ensure all the above areas are improved upon. 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 B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 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 standard(s) 1,2,3, There is insufficient information for prospective residents to be clear about the services the home. The rights and obligations of both parties is unclear. There is no assurance that residents assessed needs will be met. EVIDENCE: The corporate 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. This is used when meeting residents who are unable to visit the home. There is still no terms and conditions (or contract) available for residents who are self funding, although senior management confirm this is now being addressed. The admission assessments are not dated or signed by the author. Initial risk assessments and care plans were incomplete regarding wound, pressure sore and catheter care management. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 There are no clear or consistent care planning systems in place to adequately provide staff with the information they need to satisfactorily meet residents assessed needs. The arrangements for meeting the health care needs of residents is not satisfactory which places them at risk. The procedures and practices for the safe administration of medicines are poor placing residents at risk. Personal support is not provided to protect and promote residents’ privacy, dignity and independence. EVIDENCE: Random selections of care plans were inspected. All were found to lack the detail needed for staff to follow to ensure the residents assessed and changing needs are met. There are comprehensive assessment tools available however these were not reviewed monthly, signed or dated. There was only limited information available to show that residents and their Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 11 representatives are involved in the care planning process. On the first visit several residents were found to be very frail and unkempt with unwashed hair, nails and clothing. One resident was struggling to drink out of an empty, dark brown stained plastic feeder cup. This resident said that she missed the manager and had not been washed or changed. Both she and the room smelt of vomit and the room was rancid. Her nightdress was stiff and badly stained and her fingernails were filthy. Her hands were sticky and smelly. Her hair was very wispy, lank and greasy and when one inspector lifted her head to adjust her pillow there was dirty, crusty material stuck and congealed in her hair. Whilst one inspector assisted the resident to have a drink the other inspector found the senior nurse on duty and informed her of the physical state they had found the resident in. Two care assistants then attended to the resident. This resident’s care plan stated that she preferred to have female staff to care for her, however a male carer was brought in to wash and attend to her. Other residents were found to have “sticky eyes”, sore mouths and on this occasion 13 residents were on antibiotics for eye and mouth infections. Several of the care plans referred to pressure sores, with little evidence available of the intervention given by qualified nurses. Despite the company having comprehensive documentation for monitoring all wounds there was limited information available regarding any advice given by tissue viability specialists. Limited information was available to show that dieticians have been involved when residents have lost weight or have poor appetite. Several of the care plans were found to be out of date and not been reviewed monthly. On the second visit the food and drink charts were examined. None were completed fully. The amount of fluids recorded on several of the charts was inadequate to meet residents’ hydration needs. Records showed that some residents had not been given drinks between the hours of 5pm and 9am. One resident has had at least 5 catheter changes since March 2005 and inspectors queried the catheter size given her recorded weight. At least two residents prescribed antibiotics were not administered them 2 days later. One resident who had an extensive rash ran out of aqueous cream. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 12 On the second visit a resident was playing with a broken lamp and glass light bulbs on the windowsill. One resident was continually spitting into a plastic bin, which had no liner in it. One resident was upset, as she had received two skin injuries to her legs. The protective bandages had slipped down exposing both wounds. Another resident who had weeping ulcerated leg wounds had the knee blanket stuck to her leg. There was evidence that a suitable pressure-relieving mattress had not been supplied for a recently admitted resident. An inspection of medication was not undertaken, however it was observed that medicine rounds took over three hours in a morning. The medicine trolleys on both floors were left unattended and the trolley upstairs had dispensed tablets left on the top of the trolley. It was observed that the written transcribed medication record was not signed and there were further gaps noted on the medication administration records. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 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 standard(s) 12,15 Few of the residents’ social and recreational needs are met. The residents are not able to exercise choice and control over their diet and what they eat. The nutritional needs of some residents are not being met. EVIDENCE: The home has a designated activities organiser who arranges events both inside and outside the home. An activities programme is available and includes reminiscence, board games, arts, bingo and shopping. Several of the residents are confined to bed because of their health needs, there was limited evidence available to show that their personal preferences were being met as staff had little time to spend with them on an individual basis. The lunchtime meal was observed on the first visit and the breakfast meal on the second visit. The content and presentation of both meal looked satisfactory and residents spoken with said the food was nice. They did not know what was for lunch and were unaware that there were choices and alternatives available for all meals. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 14 Menus were not displayed and records of individual choices for each meal are not kept. On the second early morning visit residents who were up were given hot drinks however the thermos flasks were ingrained and stained black with tea stains. The kitchen assistant was able to discuss how to provide fortified drinks when residents had poor appetites or had lost weight, however the care staff did not have this knowledge. Residents who were identified as having poor appetites had food charts. These were incomplete and did not detail what residents had eaten at each meal. As stated in previous standards care planning, recording of weights and staff taking appropriate action has been inconsistent. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 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 standard(s) 16,18 The complaints policy is comprehensive, however residents are unclear about procedures and they do not feel their views are listened to. The arrangements for protecting residents are not satisfactory, placing them at possible risk of harm or abuse. EVIDENCE: There are comprehensive policies and procedures available for residents and their representatives to use should they have any complaints about the care or services. The Commission for Social Care Inspection has completed one complaint investigation and is currently investigating another complaint made by a relative on behalf of a resident. Only one complaint has been recorded in the homes complaints record since the last inspection dated February 2005. Residents spoken to were unsure who to speak to should they have a complaint. There were no records available to show that staff have received any training in Adult Protection. This has been outstanding from previous inspection reports. One complaint has generated Protection of Vulnerable Adults Multi Agency Strategy meetings, which are ongoing. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 16 Action plans have been received from the home to address the concerns and issues identified at the meetings. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,24,25,26 The standard of the environment does not provide a well-maintained, clean odour free living place for residents. There are a number of infection control and health and safety issues, which place residents, staff and visitors at risk. EVIDENCE: The location and layout of the home is suitable for the current needs of the residents. All areas of the home including a garden area are accessible to residents with disabilities and those who use wheelchairs. The home’s maintenance man continues to make some progress with redecoration of the home, however several areas of the home were not being maintained to a suitable standard. A maintenance schedule has been received from the home following the Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 18 previous inspection and this is to be monitored as part of the ongoing inspection programme. Following the first inspection visit immediate requirements were made regarding the environment and residents’ safety. An action plan was received and is also to be monitored to ensure compliance. There are lounge and dining rooms available on each floor for residents to use. The carpet in lounge 1 was badly stained, however the other lounge areas were generally clean and comfortable. The dining rooms were nicely set for all meals although there was food spillage on the walls where meals are served. There remains a problem with odour on the ground floor corridors, with the carpets being worn and stained. All of the bedrooms have en suite facilities and there are specialist bathrooms, shower rooms and toilets available close to all residents’ bedrooms and communal areas. There was a lack of maintenance, cleanliness and appropriate housekeeping in many of these areas. On the first inspection the following was found: Bathroom 2 there was a linen trolley with both clean and dirty linen and the clinical waste bag was tied to the side of the trolley. There was a plastic basket full of hair brushes which were dirty and full if different coloured hairs, a hairdryer and a tub of sudocrem which had a label stating “use as directed” and it was dated 4/3/03.Also on the trolley were numerous toiletries and an assortment of “netty knickers”. The The The The bin had no lid tiles were loose and broken shower was broken sink was dirty and the plughole full of hair. In the bathroom near to storeroom 1 the assisted bath chair was stained and soap scummed. The bath had not been cleaned. In bathroom 5 red sealant had been used to protect the plastic sheeting covering the tiles. The tiles were dirty and soap scummed. The linen trolley was dirty. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 19 There was no liquid soap. The shower attachment was broken and dirty There were broken chairs stored in the corner The bin had no lid. In all areas the position of the soap dispensers allows soap drips causing damage to the décor. The majority of the en suite facilities were found to be dirty with faeces on the floor and walls. Several of the en suites smelt of urine and soiled incontinence pads and wipes were found unwrapped in plastic bags. On the second inspection some progress had been made regarding the housekeeping and cleanliness in these areas. An action plan has been received detailing how the issues identified will be resolved within timescales. All areas still need repairs to tiling, flooring and shower replacement. The majority of the bedrooms were inspected on the first inspection by both inspectors. Some redecoration and replacement of carpets has taken place, however many of the carpets and wall coverings remain in a poor state. Many of the mattresses were stained with body fluids Bed bases were split and torn, an air mattress was falling of the bed, Large amount of nursing and medical equipment was stored, sometimes from floor to half way up the walls by wardrobes and in front of radiators Large items were also stored on tops of wardrobes The majority of the rooms were untidy with stained bed linen, dirty surfaces, food and other debris on walls and furniture. The bedrails and bedrail protectors were stained and torn. Door handles were dirty, encrusted with debris and sticky to the touch. Many of the residents’ creams and lotions are also stored in bedrooms or en suites; some of these were found to out of date or not used for the prescribed person. The problems, which were identified, were brought to the attention of the senior nursing staff and Regional Director and immediate requirements issued. The Regional Director produced an action plan of how the issues would be addressed. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 20 On the second inspection some progress regarding the residents’ bedrooms had been addressed, however concerns were again expressed regarding the ongoing problems, which were identified to the Deputy Manager and the Regional Manager. On both inspections the home was found to be comfortably warm and bright. The ventaxia units in several of the areas were switched off, when switched back on they made a screaming noise. The standard of hygiene, cleanliness and procedures for prevention of infections were poor on both inspections. Many of the identified problems have been reported in other standards on this report. Other issues, which were identified, are as follows. Both sluices were dirty with stained marked flooring. Neither of the sluice disinfectors were working There was no liquid soap to allow effective hand washing The clinical waste bins had no bags, clinical waste was stored on the floor and bins had no lids. Raised toilet seats were stored on shelving. The toilet seats were dirty and still stained with old faeces. Both sluices smelt of stale urine. Clinical waste bins were not foot operated, were not lined and were smeared with faeces inside. Bar soap was in use in communal bathrooms and several of the soap dispensers were empty. A locomotor mobile hoist was thick with dirt and dust. In the ground floor assisted bathroom the floor edges were full of dust and debris. Door handles and light switches were sticky, smeared with debris and possible body and food products. Bed tables and individual lap top trays were thick and encrusted with dirt and food deposits. The storerooms were full of clutter, clean linen was being stored on the floor The domestic cupboard was filthy with the sink and floor stained with old water spillage and other debris. The domestic trolleys were seen to be very untidy and dirty. An immediate requirement was issued regarding the state of the home and lack of adequate cleaning, and poor infection control. The inspector made a request to the Health Protection Agency Infection Control Nurse Specialist and she conducted an unannounced audit of the home and the report has been shared with home. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 21 The second inspection made by the inspectors found that the action plan produced by the Regional Director had been started, however the lack of experienced and adequate numbers of domestic staff prevents suitable cleaning to take place. There is also limited supervision of staff to ensure the required work has been completed to a satisfactory standard as the home is currently without a manager. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 22 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Residents’ needs are not being consistently met due to poor morale, staffing levels, sickness and staff turnover. The systems for recruitment and selection of staff ensure residents are protected. The provision of specialist and mandatory training is not adequate to ensure the residents assessed needs are met. EVIDENCE: The duty rotas were examined for all grades of staff. On the first visit the two homes had a designated site manager, however no shifts or work time was recorded. The new unit manager is rostered to work two days as a nurse and two days supernumerary. All of the 4 other daytime nurses are from overseas and appear to have completed their adaptation with the Company. 2 nurses are always on duty from 8am to 8pm and no agency staff are being used. 6 care staff are on duty during the day. These numbers were being achieved with the Company bank staff and an Agency staff for 4 days. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 23 In several cases only the first names have been recorded and there was no recorded qualifications for the nurses. The week of the inspection there were 2 nurses on duty five nights with 3 carers. On the other 2 nights there is one nurse and 3 carers. One of the 4 night nurses is a First level Registered Nurse and this means that Second Level nurses are taking charge alone at night. The Inspector has previously challenged these levels. On one night there were 2 nurses and 2 care staff on duty and the rota showed another shortfall for later in the week. The domestic rota is written in pencil and again includes first names only. On the day of the first visit there were 3 domestics (1 to clean carpets) and 1 laundry assistant. On 2 days there are 2 domestics and 1 laundry person. On Saturday there is only 1 domestic and 1 laundry assistant and on Sunday only 1 laundry assistant and no domestic staff. On the first visit there was an activities organiser and a new experienced administrator. The handy man has not changed although he reported that he has had to work in other homes. On the early morning second visit 2 nurses were in charge of the home assisted by 3 care staff. The home is without a Registered Manager. Six staff recruitment files were inspected and found to include, 2 references, Criminal Record Bureau checks, proof of identity and medical health checks. One overseas nurse who has undertaken the required English Language test and verification of her Personal Identification Number, which enables her to practice under Nursing and Midwifery Council requirements, was available on the day of inspection. The staff confirmed that they have received some specialist training in Palliative Care, Certifying Death and Administration of Medicines. Care staff said they had received training in infection control and first aid. Moving and handling, and fire training were found not to have been completed since last year. The staff have not received in house or external training in Adult Protection. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 24 The training records were difficult to follow, although staff have separate training files. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 25 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38 The home is not being managed properly and there is no leadership, guidance and direction given to staff to ensure residents receive consistent quality care provision. This results in practices that do not promote and safeguard the health, safety and welfare of residents, staff and other visitors. EVIDENCE: The home is without a registered manager. Support was given from the registered manager from the sister home, which is situated on the same site. The previous manager and other staff have been relocated to another home within the company. A deputy manager has now been appointed and the company are in the process of recruiting a suitably qualified manager. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 26 Given that there is not a manager the home has suffered from lack of supervision, guidance and leadership, which has resulted in the staff being unable to organise or direct service provision. Since the deputy manager has come into post some progress has been made to include the residents, staff and relatives in the running of the home. Initial staff, resident and health and safety meetings have been held with records kept. As there has been no registered manager in post formal supervision of staff has not been kept up to date. The files seen showed supervision being completed in September 2004 and some in January 2005.The content of previous recording was good. Staff spoken with at the second inspection said they had received some training in safe working practices. Records showed that fire training has not been carried out at the required intervals and moving and handling has not been carried out since last year. Records of the training are unclear about what has been provided and they lack of trainees’ signatures and dates attended. A fire risk assessment is available, however this has not been reviewed, dated and signed for the current year. None of the storerooms, which had “keep locked” signs on, were locked. The domestic cupboard was locked, however the key was left in the door, which would allow access to chemicals being stored. A brief inspection of the kitchen found that many of the items stored in the fridge were not dated or stored appropriately. The staff were hand washing all crockery and other utensils, as the dishwasher was broken. On the first inspection one resident was found to be hemmed in bed by two armchairs when the risk assessment stated that there was a high risk of entrapment with use of bedrails. This was immediately dealt with on the day and at the second inspection the resident’s bed had been moved and the appropriate action had been taken by staff to ensure her safety. The storage of large numbers of medical and nursing equipment in bedrooms, on top of wardrobes and in en suites reduces floor space and could cause toppling accidents. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 27 The home uses a large number of bedrails and bed rail protectors. There has been a visit by the Health and Safety Executive, however the risk assessments are still not up to date, nor follow current guidance. Following the visit by the Health and Safety Executive a HSE approved accident book was commenced on 1st July 2005. This is not always used to record accidents. One resident’s accident may have been documented in the care plan but the accident was not reported nor was the report available to the Commission for 2 days. Other accident reports were not easy to read or assess. Communal toiletries, used razors and tubs of Steredant were found in bathrooms and en suites. There was no evidence of risk assessments being completed. On the second early morning visit two bedroom doors were held open with footstools and when questioned the staff member said that is normal practice. The maintenance records seen were clear and up to date although they were not signed. The last recorded Health and Safety meeting was carried out in March 2005. On the first inspection of the home immediate requirements were issued to protect the health, welfare and safety of residents. The senior manager of the home provided an action plan of how the requirements would be met within timescales. On a second visit it was observed that the action plan was being implemented by the home. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 28 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 2 1 x x 1 x 1 STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 1 1 x x x 2 x 1 Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 29 YES Are there any outstanding requirements from the last inspection? 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 OP 1 Regulation 5 Requirement Timescale for action 1.11.05 2. OP 2 17 (2) Schedule 4 14,15 3. OP 3 4. OP 7 13,15 The home must produce and distribute a legible service user guide that contains all the required information. OUTSTANDING The home must provide each 1.11.05 service user with a statement of terms and conditions or contract if self funding. OUTSTANDING. The home must ensure residents 1.11.05 have a needs assessment completed which then forms the basis of a comprehensive care plan. The home must ensure each 1.11.05 resident has a care plan based on a comprehensive assessment which provides the basis for the care to be delivered. The care plan must set out in detail the action which needs to be taken by staff to ensure all aspects of the health ,personal, and social care needs of residents are met. The care plans must be reviewed at least once a month,updated to reflect changing needs and current objectives for health and personal care. All risk Version 1.30 Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Page 30 assessments must be reviewed and updated monthly.The care plans must meet revelant clinical guidance and be signed and dated by the author. 5. OP 8 12,13,14, 15,16,17 (1)(a) The home must ensure that the staff maintains the personal and oral hygiene of each resident. The incidence of pressure sores,their treatment and outcomes must be accurately recorded in the care plan and reviewed on a continuing basis. The appropriate equipment for the promotion and treatment of pressure sores must be provided according to assessed need. Advice regarding tissue viability must be sought and acted upon. The home must ensure that nutritional screening is undertaken on admission and therafter on a monthly basis.A record of residents weight must be recorded in the care plan and appropriate action taken regarding any weight changes. Advice regarding the nutritional status of residents must be sought and acted upon with appropriate records kept. The home must ensure that all medicines administered to residents are signed for on their Medicine Administration Record. The home must ensure that all medicines are administered at the required times. The home must ensure that all creams and lotions are prescribed and only administered to that resident. The home must ensure that 1.10.05 Version 1.30 Page 31 30.9.05 6. OP 9 13,17 30.9.05 7. OP 12 4,12,16 Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc 8. OP 15 14,13,15 particular attention is given to providing activities for residents with cognative impairments and for those residents who are confined to bed. The home must ensure that residents receive a varied,wholesome diet which suits individual assessed and recorded requirements. The home must ensure that there is a menu,offering a choice of meals,written in formats to suit all residents capablities,which is readily available to to them. The home must ensure that fortified foods and drinks are provided for residents who have little appetite or have lost weight. The home must ensure that a record of all complaints made by residents or their representatives is kept which details all aspects of the investigation with actions and outcomes. The home must ensure that all staff receive appropriate training for the Protection of Vulnerable Adults. OUTSTANDING The home must be well maintained at all times.A programme of routine maintenance and renewal of the fabric and decoration of the home must be produced and implemented with records kept. The carpets in the corridors and in lounge 1 require deep cleaning. The walls in both dining rooms require cleaning and redecorating. 30.9.05 9. OP 16 17,22 30.9.05 10. OP 18 12,13 1.11.05 11. OP 19 13,23 1.11.05 12. OP 20 23 1.11.05 Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 32 13. OP 21 23 14. OP 24 16,23 The shower rooms and bathrooms must be cleaned and the showers and tiling repaired or replaced. The soap dispensers require repositioning to prevent damage to walls and other protective covering The ventaxia units require repairing All bathrooms,shower rooms and toilets require bins with suitable lids. The home must ensure that all bedroom carpets are cleaned,those which are worn must be replaced. The mattresses and bed bases which are stained and split must be replaced. The home must ensure that all bed linen and towels are clean free from stains and holes. All medical equipment must be appropriatley stored. All wardrobes must be secured to the walls and personal items removed from the tops of the wardrobes. The home must provide suitable shelving in en-suite areas for residents toiletries. 1.11.05 30.9.05 15. OP 26 12,13,16, 23 The home must be kept 30.9.05 clean,hygienic free from infection and odours on a daily basis. The staff must be trained in infection control policies and procedures to minimise the spread of infection. All areas of the home must be thoroughly cleaned on a daily basis with records kept. The home must provide suitable handwashing facilities in all Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 33 resident areas. All clinical waste must be stored and disposed of according to legislation. All waste bins must have appropriate lids and bin liners. The sluice disinfectors must be repaired,the sluices kept clean and locked when not in use. The home must ensure that all spillages are dealt with appropriately and all staff provided with protective clothing. The cleaning store,domestic trolleys and equipment must be kept clean at all times. All nursing and other equipment stored in the sluices must be clean and free from stains. The home must ensure that residents personal toiletries,razors,brushes,combs creams and lotions are not shared with other residenst and are stored in their own bedrooms. The home must ensure that clean and soiled linen are stored seperately. The bedrails and rail protectors must be free from food debris and other stains at all times. The bed rail protectors which are damaged must be replaced. The home must ensure that containers used to hold sputum conform to infection control standards. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 34 16. OP 27 18 17. OP 27 18 18. OP 27 18 19. OP 30 13,18 20. OP 31 9 21. OP 32 10,12,21, 24 The home must provide adequete nurse cover at night.That is two nurses or one clinically up to date nurse with at least one senior carer who has NVQ level 3 qualification. OUTSTANDING. The home must return to the previously agreed daytime staffing levels and consult with the Commission and obtain agreement to any variation to minimum staffing levels. OUTSTANDING The home must ensure that at all times suitably qualified,competent and experienced persons are working in the home,in such numbers to meet the assessed needs of all residents. There must be sufficient domestic and laundry staff employed at all times to ensure the home is maintained in a clean and hygienic state,free from dirt,infection and unpleasant odours. The home must implement a training and development programme to ensure staff are able to meet the changing and assessed needs of residents. The home must recommence the NVQ training programme. OUTSTANDING There must be a suitably qualified 1st level nurse who is experienced and competent employed to manage the home The registered provider shall,having regard to the size of the home,the statement of purpose and the numbers and needs of the residents,carry on or manage the home with 30.9.05 30.9.05 30.9.05 1.11.05 1.11.05 1.11.05 Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 35 22. OP 36 18 23. OP 38 12,13,17, 23,37 sufficient care and skill. There must be clear direction,supervision and leadership communicated to both staff and residents, The home must resume formal 1.11.05 supervision for staff at least 6 times a year which covers all aspects of practice,philosphy of care in the home and individual carreer development needs. OUTSTANDING The home must implement 30.9.05 suitable working schedules to ensure to prevent the spread of infection and toxic conditions.All staff must understand and have a working knowledge of practices that prevent spread of infection and communicable diseases. All staff must complete up to date moving and handling training with records kept. The home must ensure that staff receive the required training in fire prevention with records kept. OUTSTANDING. The home must ensure that bedroom doors are not held open by foot stools or any other artifical means. The home must ensure that all risk assessments for the safe use of bedrails are up to date,care plans implemented that follow MDA requirements. The home must ensure that all broken glass is removed from resident areas. The home must ensure that all hazardous subtances are securely stored in line with Control of Substances Hazardous to Health Regulations (COSHH)1998 The home must ensure that all accidents are recorded both in the cre plans and on the Version 1.30 Page 36 Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc appropriate accident report. The home must ensure that risk assessments for the safe use of Steredent cleaners are implemented. The home must inform the Commision of any event in the care home which adversely affects the well being or safety of any resident. 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 OP 26 Good Practice Recommendations The recommendations following the Health Protection Agencys Infection Control Audit should be implemented as soon as possible. Willow Lodge B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 37 Commission for Social Care Inspection 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 B53-B03 S28828 Willow Lodge V227159 070705 Stage 4.doc Version 1.30 Page 38 - 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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