Inspection on 11/10/05 for Willow Lodge

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Willow Lodge 03/04/07

Willow Lodge 02/02/06

Willow Lodge 04/02/05

Willow Lodge 11/10/04

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

CARE HOMES FOR OLDER PEOPLE Willow Lodge 59 Burdon Lane Cheam Surrey SM2 7BY Lead Inspector Alison Ford Unannounced Inspection 11th October 2005 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willow Lodge DS0000019131.V254825.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. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willow Lodge Address 59 Burdon Lane Cheam Surrey SM2 7BY 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) 020 8642 4117 020 8642 7729 Trilodge Limited Mrs J E Grant Asha Paroomatee Gobin Care Home 27 Category(ies) of Dementia - over 65 years of age (0) registration, with number of places Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified resident under the age of 65 to be admitted. 4th February 2005 Date of last inspection Brief Description of the Service: Willow Lodge is a large detached residence in Cheam that is registered, with the Commission for Social Care Inspection, to provide nursing care for up to twenty-seven elderly people with dementia. It is owned by Trilodge Ltd and run as a family business with two of the directors, both nurses, frequently working in the home alongside the registered manager. The home prides itself on offering a high standard of care in comfortable, safe and homely surroundings in which the wellbeing of the residents is of prime importance. It is well served by public transport links, near to the station and local shops. Accommodation is provided in a mixture of single and double rooms arranged over two floors and there is both a passenger and stair lift. There are two spacious lounges, a conservatory and an attractive well-maintained rear garden. Various adaptations throughout the home ensure that all areas of the home are accessible to residents. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first statutory inspection for the year 2005/2006 and was an unannounced visit. The Registered Manager was on duty at the time of the inspection, which took place over three and a half hours. During this time a partial tour of the premises was undertaken and ten residents were spoken to. The care plans of three residents that had been admitted since the last inspection were assessed along with the minutes of residents meetings and the accident book. Prior to the inspection comment cards had been received from twenty-one relatives of residents in the home, and the visiting GP. An overwhelming majority of these were extremely complimentary about the home and the standard of care being delivered. Several made a special mention of the kindness of the manager and her staff. What the service does well: What has improved since the last inspection? Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 6 Since the last inspection several staff members have undertaken training, which has included health and safety, safe handling of medicines, food hygiene an understanding dementia. The staff within the home have a wide range of expertise and the care plans, showed that the physical health of some residents has improved since their admission particularly with regard to their mobility and behaviour. Since the last inspection four of the bedrooms have been decorated and thee are presented to a high standard. Two concerns from the last inspection, concerned with health and safety procedures have now been dealt with. Fridge temperatures are now correctly monitored and cleaning products are appropriately stored. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 The comprehensive pre-admission assessment, that is undertaken, ensures that residents moving into the home are confident that the home is suitable for their needs. This home does not offer intermediate care. EVIDENCE: The care plans of three residents, who had moved into the home since the last inspection, were assessed. All of them contained evidence that a full and comprehensive pre-admission assessment had been undertaken which then formed the basis of subsequent care planning to ensure that their healthcare needs remain met. There was evidence that there had been an assessment undertaken to determine the level of registered nursing input required and identify the funding arrangements. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 9 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): 7,8,10 An individual care plan, which is reviewed regularly, reflects the care being given and ensures that residents changing needs will be identified. Residents can be confident that they will always be treated in a manner, which ensures that their dignity and privacy are respected. EVIDENCE: The care plans, that were assessed, reflected the care currently being provided. Although standardised plans are used, they have been selected carefully to ensure that they are appropriate for the identified problems and compiled according to best practice guidelines. There was evidence that the physical health of some residents had improved since they had come to live in the home particularly with regard to their behaviour and mobility. Risk assessments were present and also regular review of factors, which may predispose to pressure sore formation. Several examples of pressure relieving equipment were in use in the home. The homes GP visits regularly and, in addition, all of the residents have an annual medical review. They have all had an assessment by the pshychogeriatrician to ensure that any treatment they receive is appropriate to their needs. Relatives are encouraged to participate in the care planning process and there was evidence that some had read and contributed to them. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 10 The home has recently changed its contract to dispose of waste medication, in line with current legislation. It is recommended that they write a policy outlining how the process will be undertaken in the home to safeguard both staff and residents. Staff are trained how to treat residents in a respectful and dignified manner and are monitored to ensure that this happens. They were seen addressing residents appropriately and knocking on doors prior to entering. All of the residents looked well cared for; they are supported to choose appropriate clothing and have their hair done and nails manicured and polished regularly. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 11 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 The activities within the home are suited to the resident’s abilities, providing daily interest for them and visitors are always welcome, so that links with friends and families can be maintained and encouraged. A nutritious appealing and wholesome diet helps to add variety to resident’s days and, to maintain some independence, they are supported to exercise as much choice over their lives as they can. EVIDENCE: An activities organiser ensures that a varied programme of activities takes place in the home and examples of resident’s artwork are displayed throughout the home along with photographs of events that have occurred. Relatives are always made welcome in the home and this was confirmed in the preinspection comment cards. Many of them stated that they had an excellent relationship with the staff. They are always encouraged to join in Christmas and summer parties that are held The advanced stages of dementia, of many of the residents, limits the amount of choices that they can make however, they are encouraged to select their clothes and what they would like to eat. The detailed pre-admission assessment and continued interaction with relatives helps to discover Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 12 resident’s preferences and about their previous lifestyles. This assists the staff in understanding present behaviour patterns. The lunchtime meal was served during the visit. All the residents confirmed how much they had enjoyed it; menus were seen and were varied and nutritious. There is always a choice and particular dislikes are noted. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 13 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): These standard were not assessed at this inspection EVIDENCE: Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 14 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): 19,26 This home offers an extremely well presented, well-maintained and clean environment, which meets the needs of its residents and allows them to live in a comfortable homely atmosphere. EVIDENCE: The home is situated in a pleasant residential road close to local amenities. It is well maintained and presented in good decorative order. Furniture and furnishings are homely and adaptations have been made throughout the home to ensure that it meets the needs of the residents. The range of communal space means that there can be different activities happening throughout the home at the same time. There is a large rear garden which is well used during the summer months and parking facilities to the front. Resident’s bedrooms are light and airy, all of them have washbasins and shared rooms have privacy screens available. Residents have been encouraged to personalise their rooms with items from home to make their surroundings more familiar and to retain their individuality. The home was, as usual, very clean and free from malodour. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 15 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): 27,28,30 Residents can be confident that sufficient numbers of staff are always on duty and they are appropriately trained to ensure that all of their healthcare needs can be met. EVIDENCE: Staffing levels, on the day of the inspection, complied with previously set levels and rotas confirmed that this was always so. Training for staff in this home is given a high priority; all except one newly appointed member has either completed an NVQ qualification or is undertaking it. Six staff have already gained this certificate at level 3.Other recent training has included courses in health and safety, supervision, understanding dementia, food hygiene, and safe handling of medicines. A range of trained nurses, senior and junior care staff and the activities organiser were involved in these courses. Any new member of staff would take part in a structured induction programme. Further training is planned for the near future. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, Residents and their relatives are confident that an experienced, competent and well-qualified person manages the home so that their best interests will be protected, however they are not able to express their opinions about the service that they receive in any formal way. EVIDENCE: The Registered Manager of the home, a registered nurse, has many years experience in working with this client group and a background in nurse education. She is currently undertaking an NVQ level 4 award. The two directors, both trained nurses, are also often in the home. This strong management team are able to lead by example and support the staff. There is a welcoming relaxed atmosphere in the home and the low staff turnover supports staff comments on their satisfaction with their working conditions. There are regular staff meetings and the minutes of these were seen. Relatives comment cards confirm that they are always able to approach the management team in the home however there has not been any formal quality Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 17 assurance monitoring system for some time. Relatives meetings were not well attended so the Registered Manager has agreed to consider some alternative method to seek their views on the quality of the service that is provided. The results of this must be made available to current and prospective residents and to the Commission for Social Care Inspection. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 18 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 X X X X X Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 19 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 OP33 Regulation 24(1) Requirement The Registered Manager must introduce a quality assurance monitoring system to gather the views of service users. Timescale for action 30/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It is recommended that the Registered Manager should introduce a policy stating the procedures to be followed with regard to the disposal of medicines in the home. Willow Lodge DS0000019131.V254825.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 DS0000019131.V254825.R01.S.doc Version 5.0 Page 21 - 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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