Inspection on 27/11/06 for Willow Lodge

This inspection was carried out on 27th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 08/07/08

Willow Lodge 14/06/07

Willow Lodge 09/05/06

Willow Lodge 11/01/06

Willow Lodge 11/07/05

Willow Lodge 09/02/05

Willow Lodge 07/07/04

Willow Lodge 04/02/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Willow Lodge Osborne Gardens North Shields Tyne & Wear NE29 9AT Lead Inspector Suzanne McKean Unannounced Inspection 27th November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Lodge Address Osborne Gardens North Shields Tyne & Wear NE29 9AT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 296 4549 0191 296 4570 Willow.Lodge@fshc.co.uk Cotswold Spa Retirement Hotels Limited (wholly owned subsidiary of Four Seasons Healthcare Ltd) Vacant Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (1) of places Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One place is registered to provide respite care and the person admitted may be in either the PD or OP category. One place is registered to provide respite care for named person under pensionable age. One named service user under pensionable age may be admitted to the home. No further admissions are to take place in this category without prior agreement of CSCI. 9th May 2006 Date of last inspection Brief Description of the Service: Willow Lodge is a purpose built care home with nursing that shares the site with its sister home Willow Court. The home is over two floors and each floor has en suite bedrooms, lounges and dining rooms. The first floor is accessible via the stairs or a passenger lift. There are a number of specialist bathrooms, shower and toilet facilities close to residents’ rooms and communal areas. The grounds are flat, and are accessible to wheelchair users. Some local amenities are within walking distance and the home is close to the local bus routes. There are car-parking facilities to the front of the home. Willow Lodge provides nursing and social care to older people. The home charges fees of between £332.94 and £400.78 per week depending upon the needs and requirements of the individual residents. As the home provides nursing care the free nursing care element of the funding is provided in addition to the costs charged to the resident. The home provides information about the service through the service user guide. A copy of the last inspection report from The Commission for Social Care Inspection is available in the entrance to the home. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was carried out over a total of 15 hours during two visits. A third visit was undertaken to discuss the outcomes of the inspection with the Manager. Eight residents and four staff were spoken to at some length and others chatted to briefly. No relatives were spoken to directly as there were none in the home during the first visit when case tracking. Four care plans, and records for medication were examined. Also staff files, training records and health and safety documentation was looked at. During the inspection case tracking was undertaken. This is a detailed review of individual residents care. It includes examination of their care plans and observation of the care being given to them. Case tracking also involves interviewing the resident to find out how their views about living in the home, which is dependent upon their condition and ability to communicate. Their bedroom is also looked at. The second visit was mainly to examine records although some time was spent speaking to residents and observing care being given. The third visit was to meet with the acting manager and discuss the outcomes of the inspection visits. Other information was received from an anonymous complainant, prior to the visit, which was used to inform the inspection. This information included concerns around personal care delivery and staff attitude. There was sixteen requirement made at the last inspection, thirteen of which have been met. Three requirements are outstanding and additional time has been given to allow them to be met. What the service does well: What has improved since the last inspection? Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 6 There has been significant improvement in the decoration and maintenance of the home over the past year and it is now a pleasantly decorated and well maintained. A number of the residents were complimentary about the way the home has improved and during the visits there was no sign of unpleasant odours. What they could do better: The Service User Guide must be reviewed and updated. The care plans must include details of personal care and nutritional needs, with all food, fluid and positional turn charts being completed in detail so that they can demonstrate that the care is meeting the residents needs. Residents must be treated with respect and their right to privacy maintained and staff must receive additional training to support them to achieve this. Residents must be consulted about their social interests and arrangements made for them to engage in these activities both inside and out of the home, which suit their needs, preferences and capacities. Up to date information about activities must be circulated and social interests recorded. The registered persons must ensure that particular attention is given to providing activities for residents with cognitive impairments and for those who are confined to bed. The residents must be assisted to make decisions about their care. Protection of vulnerable adults training must be provided as planned. The manager must review the staffing numbers and skill mix to make sure that at all times suitably qualified, competent and experienced staff are working at the home to meet the needs of the residents. The NVQ level 2 in care, which is a qualification for staff in looking after residents properly, must be continued as planned. Staff training and supervision must be provided to ensure that residents are treated with respect and their right to privacy maintained. The registered persons must restart formal supervision for staff. The manager must progress with their application to become registered with the Commission. A more comprehensive system of reviewing the quality of all care provision in the home, including resident surveys, must be put into place to ensure that the service is good. Where resident’s money is held by the home they must be in an account in which any interest accrued on residents money is paid into their individual account. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service user guide containing the statement of purpose, which outlines the service provided is not adequate. Residents have adequate written contracts and terms and conditions of residency. These set out the rights, and obligations of all parties. The resident needs are identified effectively during an assessment carried out prior to admission. Residents or relatives can visit the home before making any decisions to stay and receive information to help them make up their mind. EVIDENCE: The home now has a service user guide and statement of purpose, one copy of which is in the foyer at the entrance of the home. It contains the services provided and information about what is available in the home and in the local Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 10 area. This has been improved but is not complete and needs to be more detailed and provided in a variety of styles to be useful to potential residents. It is not up to date or available in a variety of formats to make them more accessible to the residents. Four care plans were inspected. They contained information that showed that assessments are carried out before any resident is admitted to the home. The Four seasons documentation is detailed and contains the necessary information for the staff to make a judgement on offering a place to residents. These assessments then form the basis of the care planning process for the resident. One resident said that they were given the opportunity to visit the home before they decided to move but they had been in hospital and had relied upon their family to choose for them. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care planning system provides staff with the information they need to meet resident’s assessed needs but is not adequate in all areas of the residents needs. The health care needs of most of the residents are being met effectively, however some residents who were physically unwell were not receiving adequate care. The records of the care being delivered on a daily basis were inadequate. The systems for the administration of medicines are currently safe and consistent. The residents are treated with respect however their privacy is not being maintained at all times. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 12 EVIDENCE: All residents have a care plan which includes a detailed assessment and a plan of care. Four care plans were looked at as part of the case tracking process and were a good standard. Risk assessments are completed for: prevention of falls, wound care, moving and assisting, and there is good care planning around areas such as continence promotion. There is an assessment to look at residents’ food and fluid intake although these do not clearly show if a fluid balance record is required. Residents access NHS services and facilities as necessary. The care plans showed that specialist advisors are used for individual residents. The home liaises with the General Practitioners who provide care to the residents. The care was being given by staff who were pleasant and courteous and number of residents were enjoying the staffs company. The care plans show that the personal and health care needs of most of the residents are being met. However the care being delivered to some of the more poorly residents was not adequate, two residents who were being cared for on the first day in their rooms were left for long periods without any stimulation or personal contact. Drinks were placed in their rooms, which they were unable to take themselves and they were not assisted on at least two occasions. On the second visit a lady who was very unwell and vomited three times was given good personal care but then left on her own after each of these occasions. She was not offered any verbal reassurance or given someone to sit with her during this episode. Staff were generally busy but two were singing along with the karaoke machine in the lounge, although it is positive that residents are being given social opportunities it may have been more appropriate to have one delegated to sit with the poorly resident. A male resident who had a urinary tract infection was unwell in the lounge, when he complained of pain the nurse explained that he often did so and that he was being investigated for the infection. However, he had not been given any analgesia. He was given pain relief at his request following the inquiry by the inspector. A drink was placed before him at 11.10 and was removed at 11:40 without it having been drunk as he was sleeping in the chair. This resulted in him not receiving the fluid although increased fluid intake is recommended in the event of a urinary tract infection. The record of fluid intake was poorly managed, the last entry on the record was 1700 and the entries were repeatedly for 200mls on a regular two hourly basis. The records did not show that the fluid intakes were being totalled to allow nursing staff to gauge if adequate amounts of fluids were being taken to Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 13 maintain fluid balance. It is unusual for residents to take exactly the amount offered and suggests that staff may be recording the amount offered and not the amount actually consumed. This was pointed out to senior staff at the second visit but had not been improved by the third visit. Residents were dressed for the activities they were undertaking and looked smart and tidy. A number of residents were positive about the care being given. An example of this is “I’m happy here” and “the staff are nice”. Generally the staff are friendly toward the residents and attempt to engage them in conversation. However some comments were made regarding the intimate needs of the residents in the public areas in the hearing of the others. Medicines management was appropriate. The staff record the medicines correctly when they are ordered. The prescriptions are then checked when they are received in the home from the General Practitioners and are then sent to the Chemist for dispensing. The medicines received from the pharmacy are checked against the record of what was ordered and prescribed so that any errors can be picked up. Medicines no longer required are disposed of safely. No resident manage their own medication. A medication error has recently occurred. The home’s management is investigating this and the Commission for Social Care Inspection will be informed of the outcome and any action to be taken as a result. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The residents are offered some social activities and are encouraged to become involved in those they find interesting and are able to take part in. this is not to a suffiecient level to give all residents opportunities to live fulfilled lifestyes. The residents are being encouraged and supported to maintain contact with their families. The residents are given a balanced, nutritious diet given at appropriate times in a satisfactory environment. EVIDENCE: There was little evidence of an organised social programme being offered and residents when asked felt that “there is not much going on”. During both visits the residents were being entertained by the staff singing along with the karaoke machine, some residents were joining in and others seemed to be enjoying it. However, there were very few other options for the residents to occupy themselves. Some were sitting in their rooms watching television or Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 15 reading. Residents were seen spending long periods of time sitting in their chairs and asleep. Those who were unwell and being cared for in their rooms were not being given any stimulation. There are no newspapers, magazines library visits, talking books or a loop system, to assist people with a hearing loss, available in the home. The residents said that their visitors are always made welcome, could visit at any time and in private. People are able to bring their own possessions with them from home such as furnishings and keep sakes. This has made their own rooms individualised, reflecting their lifestyles and personalities. There is a choice of continental or cooked breakfast and during the first visit the residents were being offered assistance with the meal. It was presented well and the staff were being courteous and helpful. On the second day the lunch was observed it was fish and chips and there was a choice of how the fish was being served. This was sampled and was tasty and served at an appropriate temperature. Cold drinks were given throughout the meal. Staff served tea to all residents during the lunch meal none was asked what they wanted to drink with their meal. Although it is acknowledged that the staff know the residents well it is preferable for the residents to be offered choices in their daily lives. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedures are clear. Residents are confident that their views are listened to or acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: The company has comprehensive policies and procedures available setting out how to make a complaint. This is being followed by the home. The procedure is displayed in the home and the staff knew how to deal with any complaints that are raised with them. The complaints records were clear, and included the investigation and the outcome. The residents spoken to were aware of the complaints policy and said that they would know who to speak to if they had any concerns. There are policies and procedures in place for Adult Protection. The staff have received in house training about how to deal with alleged abuse in the last twelve months and this training is ongoing. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 17 There is a Protection of vulnerable adults investigation being undertaken at the time of writing the report and the Regional manager of the company is involved in this. The outcome of the investigation and any action plan will be shared with the Commission for Social Care Inspection once available. Additional training is planned and will be monitored to determine its progress at the next inspection. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well decorated and maintained and offers the residents a pleasant environment in which to live. The bedrooms are particularly well personalised. Good records are maintained of the health and safety practices and maintenance of the building and facilities. The home is clean and well organised and the recent decoration has made the necessary improvements. EVIDENCE: There are lounges and dining rooms on each floor and these were clean, tidy and furnished to a satisfactory standard. The home is a smoke free area except Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 19 for designated areas, which are used by the residents who are supervised during their use. All of the bedrooms are for single occupancy. The housekeeping continues to improve and bedroom furniture, mattresses and bed linen are being replaced on a rolling programme. The bedrooms inspected were clean and tidy. Many of the residents have brought small items of furniture and ornaments with them, making their rooms individualised and homely. The laundry is separate from the resident’s areas and was organised and clean. Although there have been some recent problems with faulty equipment action taken by the acting management and hard work from the laundry staff ensured that it did not impact on the residents. The staff have some knowledge of infection control policies and procedures and the acting manager confirmed that infection control training is to be provided by the Health Protection Agency. The company have replaced the flooring in two shower rooms. There is an ongoing redecoration and refurbishment programme, which has greatly improved the appearance of the home. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There continues to be problems with the staffing in the home, the manager is off sick and there has been a temporary management plan in place involving the deputy manager and a peripatetic manager. Staffing levels have not been reviewed to ensure that adequate numbers of staff are available at “peak times of activity”. There is an effective recruitment and selection system, which ensures that staff employed are fit to work in the home. The statutory training programme is up to date however additional training must be provided around choice and maintaining dignity when delivering care. EVIDENCE: The home has experienced staffing problems throughout the year. There have been occasions when the home has been short of the necessary numbers of care staff to meet residents’ personal and health care needs. The home has always informed the Commission of the shortfalls and they try to have more staff at alternative times. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 21 There has been some success in employing care and domestic staff. Recruiting an activities organiser remains a problem. The current staffing levels being provided for the numbers and categories of residents living in the home are: 2 6 5 1 3 qualified nurses care staff care staff qualified nurse care staff 8am to 8pm 8am to 2pm 2pm to 8pm 8pm to 8am 8pm to 8am This number has been previously agreed. On the first visit to the home one of the care staff had been allocated escort duty and was therefore out of the home. The second visit, in the morning, the staff were working very hard to meet the needs of the residents but were not able to achieve all of the “task” at the usual times. Examples of this was the tea trolley being brought up to the first floor lounge at 11am and some not being served for 20 minutes as staff were called away to assist with the care of residents. The dependency of the current residents is high and the Manager has not reviewed the staffing levels for the current level of dependency in the home to ensure that adequate staffing levels are maintained. There is now adequate domestic and laundry staff employed over a seven-day period. Three staff files were inspected. These showed evidence of two references, Criminal Record Bureau (CRB) checks, proof of identity and medical health checks. Qualified nurses have their Nursing and Midwifery Council Personal Identity Number (PIN) checked to ensure they are registered to practice. Care staff are now completing National Vocation Training in Care (NVQ). However the home does not have the required 50 of care staff who have completed NVQ to level 2. Two staff have NVQ Level 3 and one person is completing this. Progress is now being made. Staff training this year has included infection control and First Aid. One of the nurses is now a moving and handling trainer so staff are receiving updates and training, however this arrangement has changed and an alternative trainer is being sought. Fire instruction and drills for staff is now up to date and ongoing training is planned according to the training schedule. Moving and handling training is up to date although ongoing training is planned for updating staff. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The systems for consultation and quality monitoring are poor, with little evidence to show that views of residents and their representatives are sought or acted upon. Residents personal accounts are managed to ensure their best interests are protected although the joint account is still being used. Staff do not receive supervision from management. This can affect the welfare of residents. The company Health and Safety policy and procedures are being followed. The temporary use of the maintenance man is effective in maintaining the fabric and safety of the building. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 23 EVIDENCE: Prior to the first visit the Regional Manager, Mr Bentley had contacted the inspector to inform the Commission for Social Care Inspection that the manager, who is not yet registered, was off work on long-term sickness. Her application for registration has not been submitted although she has been in post since January 2006. The deputy manager was to “act up” with support from another of the company managers and the regional manager. Since this management arrangement was put into place there had been improvements, including purchase of cleaning equipment (Hoover) and purchase of bedding and a hot water boiler, which were needed as a matter of urgency. On the third visit a peripatetic manager had been transferred to the home and was working with the deputy. The home no longer has a maintenance man in post. An arrangement has been made for the maintenance man from Stanton Grove (another home in the company) to work in the home some of the week while a permanent one is recruited. Monthly visits and reports from the Company’s representative are completed. There is no formal system of quality control in the home. Although some of the components for this are in place as part of the company’s procedures. Information about how the residents and their representatives are involved in the home is not detailed enough to suggest effectiveness. There is limited evidence to support that residents’ views have been taken into account. Residents’ personal allowances are held in a central non-interest bearing account. The Company is planning to change the system to enable residents to get interest on their own money. This has not yet happened. The home maintains detailed records of all transactions with cross-referenced receipts. Two people sign all of the transactions. Formal supervision for staff is not up to date for all care staff. All utility contracts were available and up to date. Accident recording and reporting is in place and the manager is completing monthly analysis. The risk assessments for the use of bedrails are being reviewed as the company has introduced a strategy to use alternative ways of managing the risk to residents. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 2 X 3 Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 26 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement The Service User Guide must be reviewed and updated. Timescales of 01/11/05 and 31/03/06 not met. The care plans must include a details social assessment and a plan of how the resident social and emotional care needs are being met. (see requirement 4 and 5) Timescales of 01/06/06 not met. The registered persons must ensure that all food, fluid and positional turn charts are completed in detail. Timescales of 01/06/06 not met. Residents must be treated with respect and their right to privacy maintained. The registered persons must consult with residents about their social interests and make arrangements for them to engage in activities both inside and out of the home, which suit their needs, preferences and capacities. Up to date information about activities must be circulated and social interests recorded. Timescale of 31/03/06 not met. The registered persons must ensure that particular attention is given to providing activities for DS0000028828.V303031.R01.S.doc Timescale for action 01/03/07 2. OP7 15 01/03/07 3. OP8 14,17 01/02/07 4. 5. OP10 OP12 12 (4) 4,12,16 01/01/07 01/04/07 6. OP12 4,12,16 01/03/07 Willow Lodge Version 5.2 Page 27 7. OP14 12(2)(3) 8. OP18 13 (6) 9. OP27 18 10. OP28 18 11. OP30 12, 18 12. OP31 9 13. OP33 24 residents with cognitive impairments and for those who are confined to bed. Timescales of 01/10/05 and 31/03/06 and 01/06/06 not met. The registered persons must ensure that residents are enabled to make decisions with respect to the care they are to receive. Timescales of 01/06/06 not met. Protection of vulnerable adults training must be provided to ensure that the staff are able to maintain the safety of the residents so far as possible. The registered persons must ensure that at all times suitably qualified, competent and experienced staff are working at the home in such numbers as are appropriate for the health and welfare of the residents. Timescale of 31/03/06 and 01/06/06 not met. The registered persons must continue with NVQ level 2 or equivalent training for care staff. Timescales of 31/03/05 and 31/03/06 & 01/06/06 not met. Staff training and supervision must be provided to ensure that residents are treated with respect and their right to privacy maintained. The manager must progress with application to become registered with the Commission. Timescale for 01/06/06 not met. The registered persons must establish a system of reviewing the quality of all care provision in the home and develop systems for consultation with residents and their representatives with records kept. Resident surveys must be published and made available to all interested parties. DS0000028828.V303031.R01.S.doc 01/04/07 01/04/07 01/02/07 01/07/07 01/04/07 01/04/07 01/04/07 Willow Lodge Version 5.2 Page 28 14. OP35 17,20 15. OP36 18 Timescale for 01/09/06 not met. The registered persons must 01/04/07 ensure that any interest accrued on residents money is paid into their individual account. Timescale of 31/03/06 and 01/07/06 not met. The registered persons must 01/04/07 restart formal supervision for staff. Timescale of 01/11/05, 31/03/06 and 01/07/06. 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 OP38 Good Practice Recommendations It is highly recommended that all bed rails have a numbering system and that details regarding hoists and slings are included in care plans. Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willow Lodge DS0000028828.V303031.R01.S.doc Version 5.2 Page 30 - 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. 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