Inspection on 27/07/05 for Willowdale Lodge

This inspection was carried out on 27th July 2005.

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

Willowdale Lodge 04/02/08

Willowdale Lodge 05/02/07

Willowdale Lodge 07/12/05

Willowdale Lodge 03/02/05

Willowdale Lodge 29/11/04

Willowdale Lodge 09/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Willowdale Lodge 21 Cromer Road Southend on sea Essex SS1 2DU Lead Inspector Carolyn Delaney Un-announced 27th July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Willowdale Lodge Address 21 Cromer Road Southend on sea Essex SS1 2DU 0170 469547 none Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sara Emma Quick CRH 14 Category(ies) of OP Old Age 14, TI Terminally Ill 7 registration, with number of places Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3/2/2005 Brief Description of the Service: Willowdale provides nursing care and accommodation for up to fourteen older people, including up to a maximum of seven people who have a terminal illness. The home is situated in a residential area of Southend on Sea, close to shops, transport and the seafront. The home provides five shared bedrooms and four single bedrooms, a lounge area and dining room. Residents also have accesss to a rear garden. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection carried out between 12.00 and 18.35 on 27th July 2005. Records including assessments, care plans, daily care notes and Medication Administration Records (MAR) in respect of four people living at the home were examined. Four residents and two relatives were spoken with during the inspection. Four members of staff including the manager were spoken with and a number of records including policies and procedures in respect of the day-to-day management of the home were examined. The standards in respect of the homes environment were not fully assessed during this inspection. What the service does well: What has improved since the last inspection? The issues identified at the last inspection in respect of checking handwritten medication records had been addressed at the time of this inspection so as to minimise the risks of errors and mishandling of medication at the home. Measures had also been implemented for checking resident’s monies held by the home. Measures had also been implemented so as to ensure that all staff were aware of the appropriate actions to take in the event of an outbreak of fire at the home, including fire safety exercises. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 6 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. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 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 standard(s) 3 & 5 Prospective residents needs are fully assessed and they and / or their family and representatives are invited to visit the home so as to ensure it is suitable to meet their needs. EVIDENCE: The registered manager visits prospective residents and carries out a detailed assessment in respect of their nursing, safety and general welfare needs and residents or their relatives are issued with a letter confirming that following the assessment that the home can meet these needs. Once residents move into the home needs are reassessed and recorded so as to ensure that staff working at the home are aware of individual’s needs. Prospective residents and / or their families are invited to visit the home and make a decision about its suitability before making a choice about moving in. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 & 11 Care plans and assessments in respect of identifying and managing risks to residents living at the home are not always written in a consistent manner so as to determine a baseline and to ensure that all staff are aware of residents needs and any changes in care and treatment. Staff working at the home ensure that residents receive medication as prescribed for them. Resident’s personal care needs are met in a manner, which respects their privacy, and their wishes in respect of end of life issues are obtained, recorded and reviewed wherever this is practicable. EVIDENCE: Care plans are not written in a consistent way, which clearly identifies what each persons nursing, and care needs are and how these needs affect their ability to carry out activities of daily living. For example in one resident care plan for nutrition it was not clearly recorded what the persons needs were or what actions staff were to take to assist and meet these needs. Resident’s capabilities were not clearly recorded so as to promote independence. Since the last inspection a system had been developed for recording residents Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 10 preferences for activities such as getting up and going to bed, bathing etc, however this was not completed for all residents whose care notes were examined. Care plans are reviewed on a regular basis. Assessments in respect of risks to residents of sustaining injuries from falls and risks of developing pressure sores/ ulcers were carried out for people living at the home and kept under review. There was no assessment of risks associated with the use of bedrails for one resident where these were used. Assessments in respect of resident’s nutritional needs were not carried out for all of the people living at the home. Residents living at the home receive medication as prescribed for them by medical practitioners and there is clear guidance for staff in respect of obtaining emergency prescriptions. At the time of this inspection none of the people living at the home had retained control of their medication, however residents, who would be capable are offered the opportunity to do so. Residents and relatives told the inspector that the care was good and residents looked clean and were dressed appropriately. Residents wishes in respect of end of life issues such as whether they would wish to be cared for in hospital or the home should their medical condition deteriorate. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 &15 The home does not always provide suitable and stimulating activities for the people who live there. Residents are happy with quality and quantities of food provided by the home. EVIDENCE: One of the care staff provides activities as part of her role within the home. During the inspection one resident was observed to be assisted with knitting which she said she enjoyed, however there was little in the way of stimulating activities provided for other residents and some residents said that there was little to do during the day. The manager and other staff said that activities are offered but that residents do not always wish to participate. Staff were advised that a review of the activities offered may benefit the people living at the home. Reflexology and massages are offered to residents on a weekly basis at no extra cost and a garden fete was planned for the weekend following this inspection. The serving of meals was not observed during this inspection, however all of the residents who were spoken with said that the food was good and that there was plenty to eat. A menu, which is updated daily and offers a choice of meals Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 12 is available in the dining room, however the majority of people spoken with said that they did not know what was available for the evening meal. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Staff act in a manner so as to protect people living at the home from abuse. Policies and guidance for staff in respect of this are not clear regarding the correct procedures for reporting any allegations of abuse. EVIDENCE: Nursing and care staff are aware of what actions to take if they suspect or witness abuse of people living at the home. The manager was reminded that any allegations of abuse should be referred to social services as per the Borough Councils Protection of Vulnerable People policy and procedure. The homes policy in respect of the protection of people who live there was not clear in respect of the correct procedures for reporting incidents of abuse to relevant parties. The manager said that she felt confident that people living at the home are protected due to the homes robust recruitment process, the low turnover of staff and the training and support which staff receive. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Willowdale provides clean, safe and comfortable communal and bedroom space for the people who live there. EVIDENCE: The home was noted to be clean and free from unpleasant odours. There are dedicated cleaning and maintenance staff employed so as to ensure that the environment is maintained in a comfortable, safe and homely manner. The home’s sluice facilities do not have hand-washing facilities for staff for when they handle soiled materials. There are plans to purchase a new sluicing machine and to install a hand basin. The regulatory requirement identified in respect of this will be brought forward for assessment at the next inspection. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 Staff are employed in sufficient numbers, trained and supported so as to meet the needs of the people who live at the home. EVIDENCE: Willowdale employs one registered nurse supported by two care staff during the day and one nurse and one care staff at night. Extra staff are required for example so as to provide an escort for residents attending hospital and other appointments, or to cover for staff absence due to planned leave or sickness. The duty rota indicated that staff do not work excessive hours and they all have appropriate off duty days. There had been no new care staff employed since the last inspection and all staff working at the home have Criminal Records Bureau (CRB) disclosures. Care staff receive regular training and support from the registered nurses and the homes manager. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 38 The home and staff are managed in a manner, which promotes the safety and welfare of the people living there. EVIDENCE: The registered manager visits the home each day and is responsible for the overall management of the service. The manager is supported by a team of dedicated staff who have worked at the home for a number of years. This consistency and low turnover of staff help to ensure that the needs and interests of the people living at the home are best served. Visitors to the home said that they are well received and that they are kept informed of any changes in respect of their relatives. There are regular checks made in respect of the maintenance of gas, electricity and fire safety in the home. Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 x x x x x x 3 Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) (2) Requirement The registered person must ensure that a detailed plan of care which describes clearly each persons nursing and care needs, how this affects their daily life and how staff can meet these needs. (Elements of this are outstanding from the last inspection) The registered person must ensure that risks to residents are so far as it is practicable identified, assessed and managed. The registered person must ensure that residents needs in respect of nutrition are asssessed in a consistent manner. (Elements of this requirement are outstanding from the previous three inspections.) The registered person must ensure that residnets are consulted about the activities they would like provided and that the range of activities is suited to their needs and wishes. The registered person must ensure that the homes policies and procedures in respect of Timescale for action 30/08/05 2. OP8 13(4)(c) 30/08/05 3. OP8 14 & 15 17(1) (a) & Schedule 3 (m) 30/08/05 4. OP12 16(2) (n) 30/08/05 5. OP18 13(6) 30/08/05 Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 19 6. OP26 23(2)(j) protecting people who live at the home from abuse is detailed in respect who must be informed in the event of witnessed or suspected abuse. The registered person must ensure that appropriate handwashing facilities are provided in areas where staff handle clinical waste. This with reference to the sluice area. (This requirement is outstanding from the previous two inspections) To be arranged. 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 Good Practice Recommendations Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend on sea SS2 6BG 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 Willowdale Lodge I06-I56 S15566 Willowdale V240852 270705 Stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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