Inspection on 05/02/07 for Willowdale Lodge

This inspection was carried out on 5th February 2007.

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

The inspector 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 07/12/05

Willowdale Lodge 27/07/05

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 Unannounced Inspection 5th February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willowdale Lodge DS0000015566.V329532.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. Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willowdale Lodge Address 21 Cromer Road Southend On Sea Essex SS1 2DU 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) 01702 469547 No Fax (13.09.01) saraequick@hotmail.com Mrs Sara Emma Quick Mrs Sara Emma Quick Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14), Terminally ill (14) of places Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Nursing and personal care to be provided for up to 14 older people. Terminally ill to include service users over the age of 55. No more than four service users under the age of 55, who require terminal illness care to be accommodated at any one time. Nursing care for service users with a terminal illness shall not exceed 14. Maximum number to be cared for shall not exceed 14. No more than two service users who are under the age of Fifty-Five years and who require general nursing care to be accommodated at any one time. 14th December 2005. Date of last inspection Brief Description of the Service: Willowdale provides nursing care and accommodation for up to fourteen older people. 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 access to a rear garden. The range of fees for accommodation at the home are £500.00 - £650.00 per week. Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced Key Inspection carried out between 10.00 and 18.30 on 4th February 2007. Records including assessments, care plans, daily care notes and risk assessment documents in respect of three people living at the home were examined. As part of the inspection process a number of ‘Have Your Say About …’ surveys were sent to the home so as to offer people living there the opportunity to express their views about what it is like to live at Willowdale. Five completed surveys were returned to the Commission. The relatives of eleven residents at the home were contacted by post so as to offer them the opportunity to make comments about the services provided by the home. Eight responded. Three residents and two relatives who were visiting the home on the day of the inspection were spoken with. Seven members of staff including the homes manager were spoken with and a number of records including duty rota’s and staff recruitment & training files were examined. A tour of the premises was carried out and the serving of lunch was observed. Each of the Key Standards as identified in the intended outcomes sections of this report have been inspected during this Key Inspection. Other standards, which have not been assessed at this time, may be assessed at the next inspection visit. Where other standards have not been inspected on this occasion they will have been inspected at the previous inspections. Reports in respect of previous inspections may be accessed via the Commissions website www.csci.org.uk Below is a brief overview of the findings of the inspection, which are covered more fully throughout the main body of the report. Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection the manager and staff have implemented the Gold Standards Framework (GSF) for planning and delivering care and support to people who are reaching the end stage of their lives. The GSF aims to provide the best care to people so that they can experience a good life and death in their preferred place of choice. There has been some work carried out in relation to the premises. The heating and hot water system has been overhauled and a new hot water boiler has been installed. A new shower was being installed in the home at the time of this inspection. Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Willowdale Lodge DS0000015566.V329532.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 Willowdale Lodge DS0000015566.V329532.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 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with information about the home so that they can make an informed decision as to whether the home is suitable and will meet their needs. This information has not been updated in light of the amendments to the Care Homes Regulations 2001such as the inclusion of fees for accommodation. Residents or their representatives/families are provided with a contract of terms and conditions in respect of the accommodation and nursing care which is to be provided by the home. Willowdale ensures that a detailed assessment of each persons nursing and care needs is carried out by a suitably qualified person before a place at the home is offered. Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 10 EVIDENCE: Willowdale Lodge has a contract with the local Primary Care Trust (PCT). The PCT commissions ten beds at the home. The remaining four beds are available for people who pay for their placement with private funding. Willowdale Lodge has a detailed statement of purpose, which describes the aims & objectives of the home and the services provided. This document had been updated in light of the recent implementation of the Gold Standards Framework for providing care for people who are reaching end of their life. People who move into the home are provided with a ‘welcome pack’, which serves as a service users guide and which includes some of the information as required by regulation. Four of the five people who live at the home and who completed ‘Have Your Say About…’ surveys said that they had received enough information about the home before making a decision to move in. The remaining person said that they had ‘moved into the home suddenly found that they liked it and decided to stay’ Of the five residents who completed ‘Have your Say About…’ surveys four said that they had received a contract when they moved into the home. On the day of the inspection there were contracts in place for all but the two people who had recently moved into the home. The manager said that she was waiting for resident’s families to sign these contracts, as the residents themselves were unable to do so. The pre-admission assessments for the two people who had most recently moved into the home were examined on the day of the inspection. Both assessments were carried out by nursing staff before the person was offered a place at the home. The documents had details of the individuals nursing and general care needs including details of medical treatment that the person was to receive. A letter is sent to the prospective resident confirming that following the assessment the home can accommodate their needs. There were no copies of these letters available for the two people who had recently moved into the home. Willowdale Lodge does not provide intermediate or rehabilitative care. Willowdale Lodge DS0000015566.V329532.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 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans, which were available for inspection, were well written and kept under regular review. However the practice of allocating the responsibility for planning care only to the ‘named nurse’ is not in the best interests of people living at the home and may put residents at risk. Where risk assessments were available these were well written and effective in minimising the risk of harm and injury to residents. Nursing staff do not always take appropriate measures to request that residents medication is reviewed when it is necessary. EVIDENCE: Of the eight residents relatives who completed survey forms six made very positive comments about the care provided by the home. One relative said Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 12 ‘they supply an excellent level of care …’. Another relative said that their aunt ‘feels safe and supported in the home…’ Of the five residents who completed ‘Have Your Say About…’ surveys four said that they always receive the care and support they need. The remaining one said that they usually did. Each of the five said that they always received the medical support they need. The care plans for three people were assessed on the day of the inspection. It was of concern to note that there had been no plan of care developed for one resident who had been living at the home for over a week. This is of particular concern as it was recorded that the person could not communicate well and that they were confused. It was reported that there was no care plan because a ‘named nurse’ is allocated to residents and where a nurse is on leave etc that care plans are completed upon their return. The manager and nursing staff were advised that this practice is not acceptable as it is not in the best interests of residents. There had only been a waterlow risk assessment completed on admission to determine the risk of this person developing pressure sores. There was a risk identified but there was no plan of care in place. The care plans for the other two people were well written and clearly identified the persons nursing and general care needs. Each activity of daily living such as eating & drinking, sleeping and mobilising etc had been assessed and where the resident was independent with the activity this was recorded. Where there was a specific need a plan of care and treatment was written. There was evidence that care plans were updated each month or at any time where there was a change to the needs of the person. Care plans, which were examined, did not include details of a person’s capability. For example for two residents where it was recorded that they require assistance with washing and dressing it was not clear as to what if any part of this activity they can complete either independently or with some support or assistance. This information would enable staff to promote independence wherever possible. Seven of the eight residents relatives who completed surveys said that they were kept informed of important matters relating to their relatives. Each of the seven said that they were consulted about their relative’s care where the resident was unable to make decisions. There were no assessments of the risks to the health and welfare of one resident despite it being identified that the person refuses most food and fluids. The assessments risks to the other two people whose care files were examined were detailed. Specific risks such as risks of falls, sustaining injury Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 13 from the use of bedrails, risks of falls etc were identified and there was clear information recorded so as to minimise the risks. Each of the five residents who completed ‘Have Your Say About…’ surveys said that they always received the medical support they need. Nursing staff were observed to administer medication to residents at the appropriate times. The Medication Administration Records (MAR) for all residents at the home were examined. The majority were well maintained with staff signatures recorded when medicines are given to residents. However there were some issues identified which need to be addressed. One resident was prescribed Metoclopramide 10mg three times a day. However this was not administered in accordance with the MAR. Nursing staff said that this was only required occasionally. The person’s general practitioner should have been requested to review the frequency of the medication. It was also noted for one person who had been admitted to the home on 28/1/07 that on admission they had been prescribed paracetamol for pain. It was recorded on the person’s admission to the home that this analgesia was not controlling the pain. However staff did not act promptly in requesting a review of this person’s analgesia despite it being recorded that the persons pain was not controlled and it was not until 5/2/07 (eight days following the persons admission to the home) that this person was provided with a stronger analgesia. Residents who were spoken with during the inspection said that they were well cared for. Residents appeared to be well looked after and were wearing suitable and clean clothing and resident’s nails, hair and teeth were clean. Since the last key inspection the home has implemented the Gold Standards Framework (GSF). This initiative was developed nationally following much discussion and debate about the best care provision for people who are nearing the end of their lives. The GSF aims to improve the quality of care for people who are nearing the last stage of life in the community so that people can live and die well in their preferred place of choice. There are a number of specific tools and resources available so as to facilitate the aims of the GSF within care homes including access to specialist services and personnel. The manager has worked extremely hard so as to implement this provision of care in the home. Willowdale Lodge DS0000015566.V329532.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 good. This judgement has been made using available evidence including a visit to this service. More could be done so as to ensure that the people living at the home are provided with the opportunity to participate in a range of occupations and activities, which are suited to their capabilities and wishes. Residents are encouraged and supported in maintaining relationships with their families and friends and are supported in making decisions about their daily lives. Residents are provided with a good choice of meals and are supported by staff at mealtimes according to their needs. EVIDENCE: Of the five people living at the home who completed ‘Have Your Say About…’ questionnaires three said that they did not wish to participate in the activities at the home. Of the other two one said that there are always activities arranged by the home and the second said that there sometimes were. During Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 15 the day of the inspection there were no activities provided. Some residents had books and magazines to read. The wishes of residents in respect of activities and opportunities for socialisation and occupation were only recorded for one of the four residents whose care notes were examined. Staff complete on a daily basis records regarding the activities, which residents have participated in. However these records were not fully completed for some residents and it was not clear from these records that good range of activities are provided by the home. For example it was recorded in some residents notes that they ‘refused activities’. It was not clear as to what activities had been offered. There is no plan in place for providing a range of activities at the home and when they are provided this seems to be on an ‘ad hoc’ basis. Staff who were spoken with said that some ‘games and exercises were offered’ but that it was very difficult to ‘motivate residents’. Each of the seven relatives residents relatives who completed surveys said that they could visit their family member in private. During the day of the inspection residents relatives and friends who visited the home were welcomed and staff were available to speak with relatives. There was evidence that residents living at the home were provided with the opportunity to make choices about their daily lives including exercising their choices in respect of the meals they have and their preferences for getting up and going to bed and arrangements for washing and dressing etc. Residents living at the home have the choice of a cooked breakfast, bacon sandwiches or cereals and toast. Residents are provided with a varied diet and there are alternatives made available to the planned meal each day. On the day of the inspection residents were seen to enjoy their meal of boiled bacon, potatoes and cabbage followed by rice pudding. Of the five residents who completed ‘Have Your Say About…’ surveys two said that they always like the meals at the home, one commented that meals were ‘excellent’. Of the remaining three, one said that they usually did and one said that they sometimes did. The remaining person is fed via PEG and so does not take food orally. Willowdale Lodge DS0000015566.V329532.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 good. This judgement has been made using available evidence including a visit to this service. People who live at the home and their relatives/representatives are aware of how to make a complaint should they need to. Complaints are dealt with in accordance with the homes policy and procedure and staff practices do not generate an undue number of complaints. Staff are provided with information and the homes policy and procedure for ensuring that people living at the home are protected form harm and abuse. More regular training could be provided for staff. EVIDENCE: Willowdale has a policy and procedure in place for dealing with complaints. Of the eight residents relatives who completed surveys four said that they were aware of this procedure. Each of the eight said that they had never had cause to make a complaint. Each of the five residents who completed ‘Have Your Say About…’ surveys said that they knew who to speak with if they were unhappy and were aware of how to make a complaint. Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 17 There have been no complaints or concerns made to the Commission in respect of the home. There had been one complaint made to staff at the home since the last inspection. A relative had complained that staff left residents unattended while they went for ‘cigarette breaks’, that they argued about the treatment a resident was to have and that the resident’s catheter bag had not been emptied during the course of a whole day. The homes manager had dealt with the complaint, which was upheld, and the complainant was satisfied with the outcome. The home has a policy for staff in respect of the protection of people living at the home from abuse, harm or neglect. From the information provided by the manager in respect of staff training it is noted that only eight out of twenty staff who work at the home had undertaken Protection of Vulnerable Adult (PoVA) training and of these only one had received training since 2005. The homes manager said that two members of staff were due to undertake this training within the next week. While this training is not deemed as mandatory it is strongly recommended that staff undertake this training periodically so as to minimise the risks to people living at the home. Willowdale Lodge DS0000015566.V329532.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, 20 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Willowdale Lodge provides clean, safe, well maintained and comfortable accommodation. EVIDENCE: Willowdale Lodge provides accommodation for up to a maximum of fourteen people. Accommodation at the home consists of four single bedrooms and five double bedrooms, one lounge area, one dining room and one quiet / visitors room. The home has four toilets, two bathrooms and at the time of this inspection a new shower was being installed. The boiler providing heating and hot water to the home had been replaced since the last inspection. The accommodation is homely in nature. Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 19 Each of the five people who live at the home and who completed ‘Have Your Sat About…’ surveys said that the home is always fresh and clean. The home was noted to be clean and free from unpleasant odours on the day of this inspection as it has been at previous inspection visits. Willowdale Lodge DS0000015566.V329532.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient to meet the needs of the people living at the home. Staff are not recruited in a consistent and robust manner in accordance with current regulation. Staff are provided with regular mandatory training and a number of staff undertake more specialist training so as to best meet the needs of the people who live at the home. EVIDENCE: Staff are employed at the home as follows: One registered nurse and two or three care workers during the day (depending on the needs of people living at the home). One nurse and one care worker at night. The duty rotas, which were provided as part of the information requested with the pre-inspection questionnaire, were assessed. These rotas covered the period between 1st January to 14th January 2007. These rotas indicate that staffing levels are maintained and that staff do not work excessive hours without sufficient breaks. The rotas did not indicate the number of hours that the homes Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 21 manager spends at the home. This was discussed with the manager who was advised that the rota must include accurate account of her hours worked. Each of the five residents who completed ‘Have Your Say About…’ surveys said that staff always listened and acted on what they say. Four of the five said that staff are always available when they need them. Of the eight residents relatives who completed surveys six said that in their opinion there were always sufficient numbers of staff on duty. Two care staff (23 ) working at the home have achieved National Vocational Qualification (NVQ) level 2 in care and further five members of staff have commenced this training. The recruitment files of one person who had been recruited to work at the home and another who was rostered to work at the home the week after the inspection were assessed. There was no documentary evidence that an interview had been carried out for the person who had been recruited and was working at the home. The homes manager said that she had interviewed the candidate before they were employed but that she had not recorded the interview. References had been obtained from a professional who had coordinated the persons work experience placement at Willowdale, the other from one of the nurses who worked with the carer at Willowdale. There was a Criminal Records Bureau disclosure (CRB) and PoVA First check in place. In respect of the second candidate it was disappointing to note that there were no references, PoVA First check or (CRB) disclosure available. The homes manager said that these had been sought and that they had been satisfactory. However an interview had been carried out by the homes manager so as to determine the fitness of the person to work at the home. At the previous key inspection shortfalls in the recruitment of people to work at the home had been identified and there was insufficient evidence at the time of this inspection that people are recruited in consistent and robust manner. Every member of staff working at the home had undertaken mandatory moving and handling and fire safety training. Six members of staff had undertake training in respect of meeting the needs of people who have dementia. Four members of staff have undertaken first aid training, two have undertaken training in respect of nutrition. Seven members of staff have food hygiene training and two have completed training in nutrition. Eight members of staff have undertaken training in respect of meeting the needs of people who have a terminal illness or who require palliative care and symptom control as part of their plan of care. Training for all staff in respect of palliative care is planned. Other staff have undertaken training in respect of managing diabetes, respiratory illness and there has been training provided in respect of care planning and managing and dealing with bereavement. Willowdale Lodge DS0000015566.V329532.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, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well managed and residents have been consulted so as to monitor and improve the quality of care and services provided. However there are a number of areas where shortfalls have been identified during this inspection. Resident’s monies and valuables are safeguarded by the homes policies and procedures. Staff are not provided with supervision, which meets the national minimum standards. Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 23 There are systems, polices and procedures in place for the safe maintenance, repair and renewal of gas, electrical, fire safety and mechanical equipment and systems in the home. EVIDENCE: Willowdale Lodge is managed by a registered nurse who is an experienced manager. The home has been managed in a consistent manner over the course of the last four years. However there are a number of areas where shortfalls in practices have been identified during this inspection, which must be addressed. There is a system in place for monitoring the quality of services provided by the home. A copy of the findings of the most recent quality assurance survey was sent to the Commission shortly after this inspection was carried out. A total of thirty people including residents, relatives, general practitioners and other healthcare professionals were contacted. A total of nineteen responses were received. The areas where people were asked to give their opinion on included decoration, facilities, food, choice, dignity and standards of care. The percentages of those who were satisfied with the quality of care ranged from 78 for decoration to 98 for accessibility. The performance of the home was compared to the results for the previous audit and performance had improved or remained static for all areas with the exception of decoration, which had fallen by 2 and facilities & garden, which had fallen by 11 . The findings of this audit will be made available to residents, their relatives and other stakeholders. The home provides a system for holding monies on behalf of residents should they wish. The records and monies for two people chosen at random were assessed. The records were maintained accurately with receipts available for all financial transactions. There is a system for supervising staff who work at the home. The supervision records for three members of staff were assessed. Records indicated that for 2006 these staff had received one supervision session, which does not meet national minimum standards. Records were available in respect of checks carried out on equipment including hoisting and lifting equipment, gas heating and hot water systems and fire fighting equipment at the home. Regular checks are carried out including weekly checks on fire alarm and emergency lighting. Staff are provided with fire safety training and participate in fire drills. A detailed risk assessment has been carried out for the home since the last inspection Willowdale Lodge DS0000015566.V329532.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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 4 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation 4, 5 & 5(A) Requirement The registered person must ensure that the information provided to those who may be considering moving into the home, Commissioners and those people who already live at the home are provided with information, (including the range of fees) as required by Care Homes Regulations 2001. The registered person must ensure that when people move into the home that a plan of care detailing their nursing and care needs be implemented so as to ensure that staff working at the home have sufficient information to provide care in a consistent manner. The registered person must ensure that risks to the health, safety and welfare of all people living at the home are assessed and so far as it is practicable that they are eliminated or minimised. The registered person must ensure that all persons living at the home receive medicines as DS0000015566.V329532.R01.S.doc Timescale for action 30/03/07 2. OP7 12 15 10/03/07 3. OP8 13(4) 10/03/07 4. OP9 12(1) (a) 13(1) (b) 30/03/07 Willowdale Lodge Version 5.2 Page 26 prescribed and that medicines are reviewed by the person’s general practitioner as necessary. 5. OP12 16(2) (m) & (n) Schedule 1(9) 17(2) Schedule 4(7) 19 & schedule 2 The registered person must ensure that residents are consulted with about their social interests and make arrangements and provisions for recreation. The duty rota must accurately reflect the hours worked by all staff including the homes manager. The registered person must ensure that all staff recruited to work at the home are only employed following receipt of all satisfactory checks as required by current legislation. This is a repeat requirement from the last inspection and the previous timescale for action of 30/12/05 has not been achieved. 30/04/07 6. OP27 30/03/07 7. OP29 30/03/07 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. 2. 3. Refer to Standard OP27 OP31 OP36 Good Practice Recommendations The rota should include details of the hours the manager spends at the home. The manager needs to ensure that where shortfalls in practices have been identified that these are dealt with promptly. All care and nursing staff should have supervision at least once every two months. Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Willowdale Lodge DS0000015566.V329532.R01.S.doc Version 5.2 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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