Care Home: Waverley Lodge

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What the care home does well Outcomes for the residents are positive. For example five residents spoken with said, "The home is nice, the staff are kind and caring, and the food is good." A good rapport between staff and residents was observed. The home has a warm and pleasant environment with a good standard of fixtures and fittings. The staff work well as a team and ensure the well-being and comfort of the residents` and treat them with great respect and kindness. People living at the home feel valued and cared for. Staff feel well supported and enabled to provide a high standard of care. Meals are varied, healthy and nicely presented offering choice and variety. Residents` health and personal care needs are well met by knowledgeable staff in an understanding way. Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. One resident said `the home is excellent; I would recommend it to anyone".` What has improved since the last inspection? Since the last inspection environmental improvements have been made with the decoration and cleaning of two rooms and the replacement of corroded commodes, to ensure residents safety and comfort. Wheelchairs have been repaired and all staff made aware of the needed for footplates to be used for the safety and dignity of the residents. Good practice in this area was observed during the inspection. Recruitment practices have been reviewed and are now robust to protect residents from potential harm. What the care home could do better: Prospective residents would benefit from an updated Statement of Purpose and Service User Guide as the current brochure and information is out of date and does not provide them will all the relevant information with which to make an informed choice. Residents would benefit from care plans and daily notes that clearly record timescales for interventions, and documented follow up of issues that arise in meeting the care needs of residents. .Residents would be better protected if all staff received training updates at the stated intervals to ensure they have the current best practice guidance. Residents respect would be better maintained if the outside of the building was decorated. Currently the paintwork is looking tired and flaking off windows and doors. CARE HOMES FOR OLDER PEOPLE Waverley Lodge Waverley Lodge 17 Albert Road Clevedon North Somerset BS21 7RP Lead Inspector Patricia Hellier Unannounced Inspection 26th September 2008 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 Waverley Lodge DS0000008073.V372360.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. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Address Waverley Lodge 17 Albert Road Clevedon North Somerset BS21 7RP 01275 873942 01275 873942 waverley.lodge@claranet.co.uk 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) Mr Mark Middleton Gostlin Mrs Catherine Jennifer Gostlin Mrs Doris Marsh Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons aged 50 years and over requiring personal care only 15th March 2007 Date of last inspection Brief Description of the Service: Waverley Lodge is a Victorian building situated in a quiet residential area of Clevedon close to local facilities. It provides personal care for up to 16 elderly people. The Home is on three floors and there are stair lifts and a passenger shaft lift to access most levels of the home. The building and décor is of a high standard providing a comfortable and homely environment. The facilities include two lounges and a separate dining room. There are 16 bedrooms of varying size and design some with en suite facilities and all have a call bell system. Provision is made within the home for a variety of activities and outings, which also enable close links with the local community to be maintained. All local facilities are within easy walking distance. The front garden allows for good weather activities outside. Garden furniture is provided. The fees range between £400 and £425 a week with additional charges being made for hairdressing, chiropody, newspapers, and toiletries. This information was provided in September 2008. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection took place over seven hours on one day. The Registered Manager, Mrs Marsh, was present throughout. Before the inspection the information about the home was received from the file held in the office, surveys received from six people who uses the service, four members of staff, two GP’s and one Health Care professional. The last inspection report was reviewed together with the completed Annual Quality Assurance Assessment (AQAA) form from the provider. The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We (The Commission) also reviewed all correspondence and regulatory activity since the last Key inspection. The accumulated evidence for this report comes from the above and also fieldwork that included discussions with ten residents, and four staff. Practices were observed and documents relating to care, recruitment and health and safety were reviewed. Of the ten resident surveys sent six were returned. The replies indicated that their care needs are met by responsive staff, and they are provided with what they need. Comments from residents were “Waverley Lodge is a first class care home in every respect”; “the home is excellent – an example of what a residential home should be”. No areas of concern were raised. All residents and other professionals spoken with told us that the home was good and the staff very kind. Comments received were “it is very homely and comfortable”; “it provides good person centred care”; “it’s a good staff team”. Responses from the GP’s and Health Care Professional told us “the home communicates well and works in partnership”; “staff take appropriate action to manage needs”. They all said they were satisfied with the overall service provision. All residents and relatives spoken with told us that the home was good and the staff very kind. Comments received were “it is very homely and comfortable”; “my relative is happy and settled”; “it’s a good staff team”. What the service does well: Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 6 Outcomes for the residents are positive. For example five residents spoken with said, “The home is nice, the staff are kind and caring, and the food is good.” A good rapport between staff and residents was observed. The home has a warm and pleasant environment with a good standard of fixtures and fittings. The staff work well as a team and ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. People living at the home feel valued and cared for. Staff feel well supported and enabled to provide a high standard of care. Meals are varied, healthy and nicely presented offering choice and variety. Residents’ health and personal care needs are well met by knowledgeable staff in an understanding way. Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. One resident said ‘the home is excellent; I would recommend it to anyone”.’ What has improved since the last inspection? What they could do better: Prospective residents would benefit from an updated Statement of Purpose and Service User Guide as the current brochure and information is out of date and does not provide them will all the relevant information with which to make an informed choice. Residents would benefit from care plans and daily notes that clearly record timescales for interventions, and documented follow up of issues that arise in meeting the care needs of residents. . Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 7 Residents would be better protected if all staff received training updates at the stated intervals to ensure they have the current best practice guidance. Residents respect would be better maintained if the outside of the building was decorated. Currently the paintwork is looking tired and flaking off windows and doors. 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. Waverley Lodge DS0000008073.V372360.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 Waverley Lodge DS0000008073.V372360.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): 1,2,3,4,5, Standard 6 is N/A Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is satisfactory and ensures that it is able to meet residents’ needs. EVIDENCE: Residents are provided with a Residents’ booklet containing the Statement of Purpose, Service User Guide and information to ensure they, or their relatives, have access to the relevant information at all times. The Statement of Purpose is currently under review to ensure that it contains all the elements required for residents benefit and information. It includes information regarding equality and diversity issues and the homes philosophy of care that includes meeting cultural and diversity needs. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 10 All residents were aware they had a contract of residency and were happy with the provision that they receive. The contracts reviewed as part of the case tracking exercise were signed and contained information about fees and the obligations of the provider and resident. The contract terms and conditions were clear and understandable. The registered manager carries out a needs based pre-admission assessment on all prospective residents. Admissions to the home take place once the registered manager is confident the residents care needs can be met. Two residents assessment documentation were read to find out how well the needs are assessed. The assessments were informative, and showed the residents had been consulted about their range of physical, mental and social care needs. There were assessments in place for each resident, that showed the Home had assessed the persons mobility needs and set out how best to support the resident safely with them. Residents were able to recall having been visited by the manager prior to admission, and also being invited to visit the home. Thus enabling the prospective residents to meet other residents, see the facilities offered and look around the accommodation available. The residents’ when spoken to said ‘I am well looked after; they know what I need”. Social services care plans had been obtained where relevant. Care practices observed showed that staff were fully aware of the residents needs as stated in their assessments. The home does not provide intermediate care Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8.9.10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ are well cared for and care plans show how to support residents with their range of needs. Residents benefit from personal and environmental risks that are well managed. Residents’ are protected by satisfactory medication administration and practices. Respect and dignity for residents’ is well maintained by kind and caring staff. EVIDENCE: Care provision for residents at Waverley Lodge is good, with staff being aware of the individual needs of residents and how best to meet them for their health and well being. The residents with whom we spoke said that they were very satisfied with the standards of care and felt the staff were good. One resident told us that the staff are “always understanding about their needs and wishes. They told us “I can do what I like and they support me. The manager is exceptionally good”. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 12 Individual records are kept for each of the residents, which include all key personal information. Two care plans were inspected and all reflected clearly current identified health and social care needs. Clear actions to met identified needs were recorded and regular evaluation noted. In one care plan it was noted that the resident has sustained a cut to their arm. The care plan had not recorded this as a need or given any clear actions as to how it was to be managed and reviewed. The daily notes recorded the injury on the day it happened but there was no record of follow through of the care of this wound. In discussion with the manager and staff they were not clear about the injury and how it was being managed, or if it had healed. The manager immediately went to follow this up. Risk assessment for pressure sore management were present in all care files clearly identifying the risks and stating actions to minimise those risk. Pressure relieving equipment was seen in use for several residents. Residents are weighed on admission, and regularly following this, to ensure they are receiving enough nutrition to maintain their health and well being. Both of the care plans inspected showed resident’s involvement. In discussion with residents although they were not aware of their care plans they talked of discussions with the staff about their needs. Staff when interviewed were clearly able to describe the needs of the residents being case tracked and demonstrated person centred approach to care. This is good practice. Health Care Professionals such as GP’s, District Nurses and the Chiropodist visit the home as required to carry out health care checks and offer advice to staff. Evidence was seen of residents being taken to other appointments as needed. Resident’s comments supported this. All care plans contained well-formulated risk assessments for Manual Handling and falls. Other personal and environmental risk assessments were present to ensure the safety of the resident while promoting independence as able. One resident said, “It is just nice to have the reassurance of someone there to help”. Daily records were up to date and written in a respectful manner. Care practices observed showed caring interactions and good communication skills from staff. Choices and preferences were observed being discussed and offered. Detailed conversations with ten of the residents confirmed a good standard of personal care. Two residents said, “it’s homely” another resident said, “people are very kind, we are well looked after” and a third said “they are very respectful and helpful”. Another resident told us “I would recommend the home to anyone - they’re the best”. Medication storage, receipt and disposal are well managed for the safety of residents. A full audit trail of medicines entering and leaving the home was possible demonstrating medicines are well managed. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 13 The Medication Administration Record (MAR) sheets had been completed with few gaps. The staff who administer medication have received appropriate accredited training and a list of specimen signatures were recorded in the medicine administration record. Hand written prescriptions had not been signed for accountability purposes. Good practice guidelines recommend two signatures for hand transcribed entries on medication Administration Record (MAR) sheets. The home does not have a policy for the administration of homely remedies. They have decided that in the best interest of residents if homely remedies are required they would seek medical advice. The interactions of the care staff observed demonstrated respect for individuals and their right to privacy. Residents spoken to say, “the staff are very thoughtful and kind and treat you very well”. All residents spoken with felt that kind and caring staff respected their dignity and privacy. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they should arise. Waverley Lodge DS0000008073.V372360.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 excellent. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from routines, and menus, that are flexible to meet their needs. A variety of activities is offered, and residents’ right to choice and control over their lives is well respected, and encouraged. Friendly staff always welcome relatives and visitors. EVIDENCE: Many residents commented on the atmosphere of the home. One person described it as nicely informal, and residents’ felt that their visitors are also helped to feel relaxed and at home. When asked about activities and their daily routine two residents said, “we have outings. Last week we went to the garden centre and before that to the fish farm”. Another told us “I enjoy the music and movement and the regular quizzes”. Staff were observed arranging transport for one resident to go to their local club. For those who are independently able there are no restrictions to going out unaccompanied. One service user said that they visit the local church regularly each Sunday. Five residents told us “there is always something going on and we enjoy it”. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 15 People who use the service told us they can see their visitors at any time, helping them to feel this is their home. Relatives spoken with told us they feel “welcomed” when they come, and that “there is a warm, caring feel to the place”. The dining room is homely and tables well presented providing an atmosphere that is conducive to an enjoyable meal. All residents said they liked the meals, and felt a good and balanced diet is provided. Choices are offered and the cook is well aware of allergies, special diets and individual’s likes and dislikes. Choices are always offered. On the day of inspection residents were observed enjoying their lunch which looked nutritious and well cooked. One resident told us “the meals are excellent with multiple choices at every meal”. All meals are home-made from fresh ingredients. In addition to the usual cups of tea and coffee, a choice of cold drinks was regularly offered throughout the day. Waverley Lodge DS0000008073.V372360.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. Residents’ are protected from abuse, and they can be confident that complaints are taken very seriously. EVIDENCE: The home has a comprehensive complaints procedure and all residents receive a copy on admission. There have been two complaints since the last inspection. These were appropriately investigated and handled, to provide the best outcome for the residents. Residents stated that if they were not happy about anything they would speak to the manager. A complaints form is available in the front hall for any resident or visitor to complete if they so wish. Residents said that the manager and staff are “very approachable” and they would always raise any concerns with them. One resident said ‘I’ve nothing to complain about, it’s just like home – we are one family”. A system for keeping clear records of complaints received, with actions taken, and outcomes are available should any complaints be received. The home has a copy of the ‘No Secrets’ in North Somerset guide and a comprehensive local policy and procedure for responding to allegations of abuse for the protection of residents. Staff interviewed were conversant with the home’s policy for protecting residents’ from abuse and demonstrated knowledge of the adult protection procedure that should be followed, if abuse Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 17 is suspected for the protection of residents. The home also has a Whislteblowing policy and staff are aware of this and their duty of care in relation to whistle blowing for the safety of the residents. Not all staff have received regular update training to ensure they have the latest guidance for the protection of residents and how to whistle blow should the need arise. Staff when interviewed were aware of the policy, had an understanding of what constitutes abuse and how best to respond to any allegations or incidents, should they occur for the protection of residents. All residents said, “The staff are very kind and take time”. “I can’t fault them”. Waverley Lodge DS0000008073.V372360.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, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with homely, safe and comfortable surroundings. Outdoor space is attractive and accessible for residents to enjoy. The home has suitable equipment to maximise resident independence. Satisfactory Infection Control practices are followed. EVIDENCE: Many parts of the home are welcoming and comfortable with homely communal spaces. Residents’ rooms are personalised and comfortable. The lounge is furnished with a variety of suitable and comfortable chairs to suit residents’ needs. Some refurbishment and redecoration of the home has taken place since the last inspection and is ongoing. The outside of the home is in need of redecoration and some repair. In discussion with the manager she was aware of some of the concerns raised and told us she would discuss with the provider. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 19 A maintenance and development plan for the home was not available to show how the provider is ensuring a safe and comfortable environment for the benefit of residents. All rooms are provided with en suite facilities for the comfort and privacy of residents. The décor, fixtures and fittings are in good order. The lounge is furnished with a variety of suitable and comfortable chairs to suit residents’ needs. The home has a well maintained garden for residents to enjoy. Residents’ rooms are personalised and comfortable to suit their needs. There are plenty of toilets within easy access of all communal rooms, for the comfort of residents. The home has grab rails situated at relevant points and a stair lift to all floors that is easily used to assist resident mobility, and aid independence within the home. The home has sufficient bathroom facilities with aids for the benefit of residents. Equipment was clean and well maintained to ensure the protection of residents from cross infection. Hot water outlets are all thermostatically controlled to prevent potential incidents from scalding water. Thermometers were present for staff to check the water temperature before baths for the safety and protection of residents. All radiators in the home have been covered to safeguard residents from potential harm. The home was clean and free from offensive odours throughout. The laundry facilities were organised to minimise potential cross infection. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. In the entrance to the laundry we saw an open pad bucket being used to prop open the door. Staff should be aware of the potential for spreading infection through this practice. Dispenser soap and paper towels are provided in communal areas, to facilitate good hand washing practices, between caring for residents and reduce risk of cross infection in the home. Waverley Lodge DS0000008073.V372360.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 good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by a sufficient number of competent trained staff. Residents are protected by safe recruitment practices. EVIDENCE: The staffing rotas for the two weeks prior to the inspection were reviewed. Staffing levels appear to provide sufficient care staff to meet residents’ needs. A good team of ancillary staff supports them. In discussion with residents they told us “the staff are very good and always there when you need them.” Other comments received were “staff know their job and do it well”. The roster does not always include the ancillary staff and manager’s duties to show who was working in the home for accountability purposes. Staff interviewed, and surveys responses from staff, told us “we seek to provide a high standard of care to residents”. “There are good relationships between staff, residents and their families”. “We provide a safe and serene service for residents, where everything is well managed and updated regularly”. Feedback from the Health Care Professional told us “the home provides good all round care”. The home currently has more than 50 of staff with a National Vocational Qualification (NVQ). Staff are looking to increase their qualifications to ensure Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 21 they have the skills and knowledge to care for the residents in a safe and competent manner. Since the last inspection safe recruitment practices have been implemented to ensure residents are protected from potential harm. Two recruitment files were inspected and all required documentation was present to ensure residents are protected from harm. All staff interviewed stated they had contracts of employment and job descriptions. Evidence was seen of staff induction in the files of two new members of staff to ensure they have the skills and knowledge to care for residents appropriately. Moving and Handling training is not included in the induction. It is recommended that this is provided for the safety and protection of residents and staff. When interviewed we were told that the induction “was helpful and covered all the things I needed to know”. We were also shown the induction booklets that new staff are working through to ensure they are provided with the relevant knowledge and assessed as competent for the benefit of residents. Since the last inspection the home have worked hard to provide training in a number of areas, both mandatory and specialist to ensure staff have the skills and knowledge to meet residents’ needs. The development of a training plan would ensure all staff receive the mandatory training within the designated timescales. Records inspected showed that staff have attended a wide variety of training offered including falls awareness, continence care, diabetes and dementia. Evidence of this was seen in the training records inspected. The staff spoken with confirmed they had undertaken training and demonstrated good knowledge and understanding in the areas of food hygiene, fire precautions and safeguarding adults, thus ensuring that residents are cared for by competent and knowledgeable staff. Waverley Lodge DS0000008073.V372360.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): 31.32.33.35.36.38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a well run home which has their interests and safety at the heart of decision-making. Quality assurance processes in the home are formal demonstrating that the home consults with residents, families and visiting professionals. Resident’s can be confident that monies held for them by the home are well managed. Health and safety issues are monitored in the home to ensure that issues are identified and addressed where they arise. EVIDENCE: The manager is qualified and has a number of years experience in this area. She has good skills and knowledge and has obtained her Registered Manager’s Award. The manager gives leadership, guidance and direction to staff to Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 23 ensure they are knowledgeable and competent to meet the needs of people who use the service. The providers are involved in the day to day running of the home. Residents told us “they are often here and are very nice”. “They always listen”. People who use the service and other professionals feel the manager is approachable, available and seeks to ensure the needs of all residents are met. One resident said she ‘can’t do enough’, ‘she is always helping”. Staff interviewed stated that they felt supported by an approachable manager. Policies are in the process of being reviewed and best practice guidance included in them, for the benefit of residents. Staff are aware of the policy folder and can access it as needed. A formal quality assurance tool was available for inspection in order to demonstrate that the home consults with residents and relatives. A summary report of the most recent survey was not available at present as it is currently being prepared. The manager told us that she would feedback the results at a residents meeting and the outcome issues discussed. Minutes of residents meetings held since the last inspection show how residents can have their say, and their suggestions incorporated into the running of the home. Pocket monies, for people who use the service, held by the home, were inspected and found to be accurate and to have clear records for the protection of residents. Not all entries were supported by two signatures for any transactions made for the safeguarding of both residents and staff. This is recommended as good practice. Records inspected showed staff have received regular supervision to ensure they have the skills and knowledge to meet resident needs. Staff spoke of receiving this and it’s helpfulness in identifying areas of training they would like, and would benefit their care provision to residents. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that fire instruction and drills had taken place. Not all staff have received fire training within the prerequisite timescales. This must be provided for the safety of residents. We observed a number of fire doors wedged open. In discussion with the manager she told us that risk assessments had been undertaken and measures identified to reduce the risk in the daytime. Risk assessments were seen to verify this comment. She told us the wedges are removed at night for the safety of residents. We were also told that a programme of door releases attached to the fire alarm is in the progress of being completed to allow for the removal of door wedges. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 24 The home stores records securely and uses them in accordance with the Data Protection Act 1998. Records are accurately maintained to ensure clear information for the provision of knowledgeable and consistent care to residents. Records indicating regular maintenance to gas and water systems were seen, together with servicing records for all equipment. Recommendations raised by these professionals are responded to in a timely manner. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 3 3 3 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 3 2 Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 26 NO 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 OP19 Regulation 23.2(b) Requirement The registered person must ensure that the outside of the building, including the top fire exit door, is kept in a good state of repair externally. The registered person must keep a clear roster of people working in the home and if that roster is worked. Timescale for action 31/12/08 2. OP27 17.2 Schedule 4 30/11/08 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 OP7 Good Practice Recommendations The registered person should ensure that as care needs arise due to accident they are recorded in the care plan with clear actions to meet those needs. Daily notes should evidence follow up of the incident to resolution or further treatment. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 27 2. 3. 4. OP26 OP30 OP38 The registered person should ensure care staff are aware of infection control issues when using pad bins. A training plan should be developed to ensure staff receive mandatory training updates within the recommended timescales. The registered person should ensure that all fire door wedges are replaced with door releases for the safety and protection of residents. Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Waverley Lodge DS0000008073.V372360.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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