Inspection on 09/05/06 for Willow Lodge

This inspection was carried out on 9th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willow Lodge 08/07/08

Willow Lodge 14/06/07

Willow Lodge 27/11/06

Willow Lodge 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 Mrs Irene Bowater Key Unannounced Inspection 9th May 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.V289426.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willow Lodge Address Osborne Gardens North Shields Tyne & Wear NE29 9AT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 296 4549 0191 296 4570 willow.lodge@fshc.co.uk Cotswold Spa Retirement Hotels Limited (wholly owned subsidiary of Four Seasons Healthcare Ltd) 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.V289426.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One place is registered to provide respite care and the person admitted may be in either the PD or OP category. One place is registered to provide respite care for named person under pensionable age. One named service user under pensionable age may be admitted to the home. No further admissions are to take place in this category without prior agreement of CSCI. 11th January 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. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place over eight hours and was carried out by two inspectors The home had an additional inspection visit in March 2006 to monitor how the home is meeting the requirements from previous inspections. Letters and other correspondence in relation to the reports with the provider are available at the CSCI office. The Company have responded the issues raised and continue to work with CSCI and other Agencies. Over the course of the day a tour of the premises took place and residents, relatives and staff were spoken to. Care records and other home records were also inspected. Surveys of residents were also carried out. What the service does well: What has improved since the last inspection? The home continues to make many improvements to the environment and care since the last inspection and subsequent additional visits. The requirements from these inspections are being met and an improvement and refurbishment plan has been provided to the Commission. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 6 There is a manager and a deputy. They are starting to address the issues of concern in the home. The staff continue to work with all specialist nurses and other agencies to improve the care. There is a marked difference in the cleanliness and freshness in the home and staff are now receiving infection control training. Surveys included comments that general improvements are being made in the home, although two said the home still had a long way to go. What they could do better: Further development to the Service User Guide is needed as the one available is out of date and it does not clearly say what the home provides. Although some improvements have taken place to care plans, further work is needed so that they are clear and detailed about the care provided. The staff need to fill in all the charts to show what help poorly residents have been given throughout the day. Improvements are needed to the medicine records. The recruitment of an activities organiser is necessary to improve the quality of life of residents living in the home. Comments from residents include “I get bored here, just watching TV. Sometimes I fall asleep”, “I get sick of being in this room”. “ Staff come and talk to you, sometimes”. Further training for staff is needed so that they can continue to improve the lives of people in the home. The consultation with residents and their representatives’ needs to improve so that they feel their concerns are listened to at all times. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 7 There needs to be a strong leadership style to create open and positive management in the home. Refurbishment and redecoration of the home needs to continue as agreed with the Commission. Health and Safety issues, including risk assessments, must be reviewed to keep residents, staff and visitors as safe as possible. All of the requirements from this report need to be met within the timescales. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. There is insufficient information for prospective residents to be clear about the services the home offers to provide. The admission assessments ensure the residents care needs will be met. EVIDENCE: The Statement of Purpose and Service User Guide still remains incomplete and out of date. This is due to there being no designated manager in post since April 2005.The new manager is aware that these documents need to be reviewed as soon as possible. The care plans showed that the care managers and the home’s staff carry out admission assessments. These assessments form the basis of the care planning process. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Further improvements to the care plans and other records will mean that the staff have sufficient information to meet all of the residents assessed needs. The health needs of residents are currently being met. There is interagency working. The lack of detailed recording for medicines has the potential to place residents at risk. Personal support is currently promoting residents right to privacy and dignity. EVIDENCE: Some care plans were inspected. The nursing staff are working hard to review all of the care plans to make them clear and up to date. There was some improvement in care plans, however the risk assessments are not updated, and care plans are not all evaluated on a monthly basis. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 11 Relatives are involved in developing the care plans and agreements are signed. The care plans refer to preferences about residents’ choice for female carers. All residents can use NHS facilities. Specialist advice is sought when necessary should residents be at risk from pressure sores. The staff have a detailed care plan for a resident with pressure damage, which they have successfully treated. The food, fluid, and positional turn charts are available but are still not being completed in detail. The medicine administration records showed no gaps in recording. The records are now being written out in full and hand written directions had two signatures to reduce the possibility of mistakes. A random audit of the Controlled Drugs was satisfactory. The home does not maintain record books of medicines received or returned to the pharmacy; therefore an audit was not possible. The treatment room has been cleaned and organised and the drugs trolley on the upstairs unit is now secured in the treatment room. Service users have access to the telephone and are able to have their own telephone in their bedrooms. People are called by their preferred name. This is identified in the care plan and staff were heard to use them. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 12 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Social activities do not provide stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with opportunities to maintain their previous lifestyles. Residents are not fully supported to make choices and take control over their lives. The choices and presentation of meals is not satisfactory to meet residents’ individual needs. EVIDENCE: On the day of the inspection there were no structured activities. Residents were seen spending long periods of time sitting in their chairs and asleep. One resident spent all day lying on his bed but was not unwell. He had no stimuli. He welcomed a chat with the inspector. Some residents spend time in their own rooms with no apparent stimulation. At about 4pm the TV sound was loud and cartoons were on. No one was watching. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 13 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 hairdresser was present during the day. One service user who is a Roman Catholic requested communion upon admission to the home but he is not receiving this. The manager said that a karaoke session has taken place and there has been an Easter Bonnet party. The manager agreed that there was a lack of activities and stimuli and is committed to improve the quality of life for residents. Visitors were seen to come and go throughout the day. Visitors are made welcome and are able to take residents out. Residents are able to manage their own finances for as long as possible. People are able to bring their own possessions with them from home such as furnishings and keep sakes. Residents do not actively make many choices in the home. Personal preferences are not recorded in care plans. Pre- Assessments of care were examined and choices identified have not been acted upon. One resident who is partially sighted wanting talking books, but these had not been provided Despite menus being displayed in the dining rooms, on weekly menus and in large print on a white board, residents were still unsure what they were going to eat. It was difficult to find out what individual residents have eaten over a period of time. Choices available for each meal are not specified. An Inspector joined the residents for lunch. The tables were set, but the cutlery was stained and no condiments were provided. The staff did not provide any adapted cutlery or plate guards to enable residents to eat their meal with dignity or to promote independence. The meal provided for a resident who had difficulty in swallowing was presented in a dessert bowl with meat, potatoes, vegetables and gravy mixed together. Hot and cold drinks were offered throughout the day. The thermos flasks have been replaced since the last inspection. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The complaints procedures are clear. Relatives and residents are not confident that their views are always listened to or acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: The home has policies and procedures for residents and staff to use should they have any concern or complaint about the care or other services. There have been several complaints made by relatives and residents, which have been investigated and resolved by the Commission, with full cooperation of the home. On the day of inspection the complaints book was not available and was found in the treatment room under a pile of medicine administration records. There have been no entries in the book since February 2006. There have been no complaints made since the last inspection. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 15 The employment of a manager and deputy manager should improve the concerns raised in the home. There are policies and procedures in place for Adult Protection. The staff have implemented the procedures with good effect in December and March 2006. None of the allegations were upheld. The staff have received training about how to deal with alleged abuse in the last twelve months and this training is ongoing. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 21,24,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. There has been some investment in the home, which continues to improve the conditions for the people who live there. There are still some outstanding requirements that have the potential to place residents at risk. EVIDENCE: All areas of the home are accessible to residents with disabilities and those who need to use wheelchairs. Since the last inspection and subsequent additional visits, improvements have been made to all areas, and a programme of redecoration and refurbishment is now in place. There are lounges and dining rooms on each floor and these were found to be clean, tidy and furnished to a satisfactory standard. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 17 All of the bedrooms have an en-suite toilet and hand washbasin and there are bathrooms, shower and toilets close to all bedrooms and communal areas. The company have agreed the replacement of the flooring in two shower rooms and the manager confirmed that they are waiting a fitting date. This is a requirement. The following were found on an inspection of the toilets and bathrooms: There is water damage to the ceiling in the downstairs bathroom The bathrooms and toilets did not all have suitable foot operated bins with lids. The flooring in bathroom 5 is damaged and worn The shower attachments are loose and broken The sluices still have an unpleasant smell All of the bedrooms are for single occupancy. The housekeeping continues to improve and there is evidence that 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 furniture with them, making their rooms individualised and homely. The laundry is separate from the residents areas and was organised and clean. Since the last inspection the home have provided suitable containers to store soiled linen, which has reduced the risk of infection. The staff have some knowledge of infection control policies and procedures and the manager confirmed that infection control training is to be provided by the Health Protection Agency. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The lack of a consistent, fully trained staff team has had a detrimental impact on the quality of care provision in the home. Improvements taking place with staff records will ensure residents are protected from harm. 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. There has been some success in employing care and domestic staff. Recruiting an activities organiser remains a problem. An experienced manager and deputy have been employed and they have started to address these issues. The current staffing levels for the numbers and categories of residents living in the home are: Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 19 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 On two nights there are 2 qualified nurses and 2 care staff on duty. There are now adequate domestic and laundry staff employed over a sevenday period. There is a chef and one kitchen assistant throughout the week. An administrator and a maintenance person are employed. The manager is supernumerary. Five 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. It was confirmed that a full audit of the staff files has been completed and four staff that have been employed for a long time did not have a CRB check in place. This was being addressed by the home. Care staff are now completing National Vocation Training (NVQ). 33 of care staff have completed NVQ to level 2. Two staff have NVQ Level 3 and 1 person is completing this. Five care staff are completing level 2. Good progress is now being made. The new manager is organising training for staff and improving the training records. New staff spoken to confirmed that they have received induction training. New training 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. Staff do not all have mandatory training in Food Hygiene, fire safety, health and safety and protection of vulnerable adults. Fire instruction and drills are still not occurring at the home. An immediate requirement was given to the manager to ensure that all night staff receive this training by 15.5.06. Training records were difficult to follow and were not up to date. NVQ training has been put on hold and should recommence in the near future. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The home now has a manager who has started to show guidance and direction to staff which should promote quality care. 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 not managed to ensure their best interests are protected. Staff do not receive supervision from management. This can affect the welfare of residents. There are poor health and safety practices which pose potential risks to residents, staff and visitors. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 21 EVIDENCE: A new manager has been in post since January 2006. She is a first level registered nurse with experience in managing and caring for older people. She has started to address the many issues the home has in aspects of the service provision. She has yet to complete her application to become a registered manager with the Commission. Monthly visits and reports from the Company’s representative are completed. The new manager has held one resident and relative meeting to consult with people. There is no formal system of quality control in the home. Information about how the residents and their representatives are involved in the home is not available. 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. Not all of the transactions are signed by two people. Formal supervision for staff has not started again. The new manager intends to introduce this in May. All utility contracts were available and up to date. Accident recording and reporting is in place but the manager is not completing monthly audits. Staff have not received fire instruction and drills at the appropriate intervals. An immediate requirement was issued to the home to ensure that night staff are trained by 15 May 2006. The outstanding requirement was addressed by the 12 May 2006. The risk assessments for the use of bedrails do not have a numbering system to ensure that accurate records of inspections are kept and maintenance is undertaken. The care plans do not detail the specific hoist and sling to be used for each individual resident. Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 1 X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 2 2 X 2 Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement The Service User Guide must be reviewed and updated. Timescales of 01/11/05 and 31/03/06 not met. The registered persons must review all of the care plans to ensure they are up to date and set out the action to be taken in regard to health, personal and social care needs. Timescales of 01/11/05 and 31/03/06 not met. The registered persons must ensure that all food, fluid and positional turn charts are completed in detail. The registered persons must ensure the record all medicines received and disposed of is maintained, to enable a full audit trail. 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 DS0000028828.V289426.R01.S.doc Timescale for action 01/07/06 2. OP7 13,15 01/07/06 3. OP8 14,17 01/06/06 4. OP9 13,17 01/07/06 5. OP12 4,12,16 01/07/06 Willow Lodge Version 5.1 Page 24 6. OP12 4,12,16 7. OP14 12(2)(3) 8. OP15 12,16 9. OP16 17,22 10. OP19 23 11. OP21 23 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 residents with cognitive impairments and for those who are confined to bed. Timescales of 01/10/05 and 31/03/06 not met. The registered persons must ensure that residents are enabled to make decisions with respect to the care they are to receive. The registered persons must ensure that residents receive a varied, appealing and nutritious diet, which is suited to individually assessed and recorded requirements. Food, including liquefied meals, must be presented in a manner that is attractive and appealing in terms of texture, and appearance, in order to maintain appetite and nutrition. The registered persons must ensure that all complaints are recorded, and detail the investigation and any other action taken. The registered persons must ensure that the home is of sound construction and kept in a good state of repair externally and internally and complies with the requirements of the local fire service. The registered persons must replace the flooring in the shower rooms. All of the extractor fans must be cleaned. All bathrooms, shower rooms DS0000028828.V289426.R01.S.doc 01/07/06 01/07/06 01/07/06 01/07/06 01/07/06 30/06/06 Willow Lodge Version 5.1 Page 25 12. OP24 16,23 13. OP27 18 14. OP28 18 15. 16. 17. OP29 OP31 OP33 19 9 24 18. OP35 17,20 19. OP36 18 and toilets require bins with suitable lids. Timescale of 01/11/05 not met. The registered persons must continue with the replacement of bedroom carpets, beds and linen. 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 not met. The registered persons must recommence NVQ level 2 or equivalent training for care staff. Timescales of 31/03/05 and 31/03/06 not met. The registered persons must ensure that all staff have Criminal Record Bureau checks. The manager must progress with application to become registered with the Commission. 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. The registered persons must ensure that any interest accrued on residents money is paid into their individual account. All entries require 2 signatures. Timescale of 31/03/06 not met. The registered persons must restart formal supervision for staff. Timescale of 01/11/05 and DS0000028828.V289426.R01.S.doc 30/06/06 01/07/06 01/07/06 01/06/06 01/08/06 01/09/06 01/07/06 01/07/06 Willow Lodge Version 5.1 Page 26 20. OP38 23 31/03/06 not met. The registered persons must ensure that all in house maintenance and risk assessments are up to date and signed. Timescale of 31/03/06 not met. 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.V289426.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willow Lodge DS0000028828.V289426.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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