CARE HOMES FOR OLDER PEOPLE
Willow Lodge 59 Burdon Lane Cheam Surrey SM2 7BY Lead Inspector
Alison Ford Unannounced Inspection 2nd February 2006 12:30 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 DS0000019131.V276308.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 DS0000019131.V276308.R01.S.doc Version 5.1 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.V276308.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th October 2005 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.V276308.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second statutory inspection for the year 2005/2006 and was an unannounced visit. The Registered Manager was not on duty at the start of the inspection, although she arrived later, and the senior nurse on duty is thanked for her help and hospitality. The inspection took place over three hours during which time a partial tour of the premises was undertaken and five residents were spoken to. The care plans of two residents that had been admitted since the last inspection were seen and certificates of worthiness for the equipment in use in the home. The GP who attends the home was also there this being his usual day for visiting. Over the course of the two inspections all of those standards considered, by The Commission, to be key to the inspection process have been assessed and this report should be read in conjunction with the one produced following the inspection on 11th October 2005. What the service does well:
This home continues to offer a consistently high standard of care, in an attractive well-maintained and homely environment, to elderly people with dementia. Verbal communication with the majority of the residents is limited however they are always very happy and contented and the atmosphere is warm and welcoming. Residents are always appropriately dressed and clean, ladies have their nails manicured and their hair regularly styled. Comments received from those who are able, confirm their satisfaction with the home, saying that they “like living here “ and “everyone is very kind” and this view is echoed by their relatives and by the visiting GP. A comprehensive pre-admission assessment ensures that residents healthcare needs will be met and their individual care plans are reviewed regularly so that they are receiving the most appropriate support. Advice is sought from other healthcare professionals as necessary. There are regular organised activities, which add interest to residents lives and a varied and nutritious choice of meals is served. Photographs illustrate events that have taken place in the home. The staff, working in the home, have a wide range of expertise and the care plans, showed that the physical health of Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 6 some residents has improved since their admission particularly with regard to their mobility and behaviour. Staff training in the home is given high priority and all members of staff are able to access courses that are appropriate to the work that they undertake. Both qualified nurses and care staff are able to undergo this training together. The majority of the care staff are educated to at least NVQ level 2, several to NVQ level 3 and the management team actively support staff development What has improved since the last inspection? 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.V276308.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 two residents, who had moved into the home since the last inspection, were assessed. Both 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. Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 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): 7,8,9,10 An individual care plan, which is reviewed regularly, reflects the care being given and ensures that residents changing needs will be identified and medication policies and procedures are in place to protect them. 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. 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. Medication storage, administration and records were all in order. Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 10 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): These standards were not assessed at this inspection. EVIDENCE: Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 11 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 Residents can feel confident that any complaints that they may have will be treated seriously and responded to appropriately and that they will be protected from abuse. EVIDENCE: There is a complaints procedure displayed in the home although no complaints have been made since the last inspection. No members of staff have been referred for inclusion to the Protection of Vulnerable Adults Register and preemployment checks for staff are always comprehensive. The Registered Providers and Registered Manager are frequently in the home and would be able to deal with any concerns promptly when they arise. Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 12 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, complies with fire safety regulations and is 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
Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 13 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.V276308.R01.S.doc Version 5.1 Page 14 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): 28,30 Residents can be confident that the homes recruitment policies will ensure their protection and that staff are trained and competent to do their jobs. EVIDENCE: This standard had previously been assessed and there has not been any new member of staff appointed for some time. Staff turnover is very low in this home, which provides the residents with continuity of care and a feeling of safety and familiarity. Staff training continues to be given high priority in the home with all members of the staffing team being encouraged to attend training courses, together, relevant to the work that they perform. As well as increasing the knowledge of staff the process of them all undertaking the training together promotes a team feeling with them all helping each other and being able to contribute a different perspective. Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 15 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): 33,35,38 Residents can feel confident that the home is run in their best interests and that procedures are in place to ensure their safety. EVIDENCE: A quality assurance monitoring tool has been introduced since the last inspection. Questionnaires, designed to monitor the satisfaction of those who use the service, have been distributed and replies are in the process of being collated. The home does not take responsibility for the finances of any of the residents they all have relatives or representatives to do this for them. Certificates of worthiness and maintenance for the equipment in use in the home and to protect the safety of residents were seen and were in order. Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 16 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 17 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willow Lodge DS0000019131.V276308.R01.S.doc Version 5.1 Page 18 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
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