Inspection on 10/07/07 for Waters Edge Care Home

This inspection was carried out on 10th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Waters Edge Care Home 11/10/06

Waters Edge Care Home 17/01/06

Waters Edge Care Home 31/08/05

Waters Edge Care Home 19/10/04

Waters Edge Care Home 05/05/04

Waters Edge Care Home 12/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lakeside Residential Home Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA Lead Inspector Mrs Kathryn Marks Draft Unannounced Inspection 10th July 2007 09:00 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 Lakeside Residential Home DS0000004968.V340737.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. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lakeside Residential Home Address Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA 01922 409898 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) Ralton Care Homes Limited Mrs Sandra Potts Care Home 63 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (63), Physical disability (6), Physical disability over 65 years of age (10) Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 6 may be Physical Disability minimum age 55 years on admission 3-Day Care places not to go above the 63 places registered. Date of last inspection 11th October 2006 Brief Description of the Service: Lakeside is a sixty-three bedded care home situated in Great Wyrley on the main A34 Cannock to Walsall Road. Public transport passes by the home. Residents accommodation is situated on the ground and first floor, the first floor being accessed by a passenger shaft lift. There are four shared bedrooms and fifty-five single bedrooms all of which have en/suite facilities. There are three lounges and a dining room on each floor, six bathrooms all of which have assisted bathing facilities, plus two shower rooms. Separate toilets for communal use are appropriately sited around the home. Purpose built home maintained to a high standard. The continence advisor, chiropodist, optician, audiologist, specialist diabetes nurse, district nursing service and any other medical specialist or consultant that service users need to access are available to them. Information gained from the Care Manager at the time of inspection identified that the current fee’s charged are £400 to £415 per week. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced Inspection was carried out on 10/07/07 and covered all of the core standards. The inspection took place over one visit totalling 7.5 hours by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. Lakeside has in place a Statement of Purpose and Service Users Guide to inform people who use the service of the services and facilities provided. A tour of the home took place with staff. People who use the service were visited in their bedrooms or spoken to in lounge areas. The inspection included an examination of records systems and procedures in place at the home, observation of daily routines, and conversations with people who use the service and staff on duty. Observations were made of five care plans and accompanying records of individuals. Information was obtained from people who use the service, in relation to their views of the service and care provided at Lakeside. Individuals indicated during conversations with them that, as at previous visits generally they were happy with the manner in which services are provided to them at the home. The accommodation of people who use the service is located on the ground and first floor and observations were that the home was clean comfortable and individual bedrooms were very personalised. The Care Manager and the pre inspection documentation provided information regarding staffing, staff training, menu and dietary provision. A full assessment of individual needs is carried out prior to admission to the home assessments of the last three service users admitted were observed at this visit. The homes complaints procedure is displayed along with details of how to contact the Commission for Social Care Inspection. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Complete the updating of Statement of Purpose to include staff qualifications. Highlight allergies of people who use the service in alternative colour. Put protocol in place for nail care. More detail in records of Doctors Visits for instance “why called” “treatment prescribed” Staff files to be tidied up and maintained up to date. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lakeside Residential Home DS0000004968.V340737.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 Lakeside Residential Home DS0000004968.V340737.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): Standards 1,3 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home has in place a Statement of Purpose and Service Users Guide that provides prospective people who use the service with information about the services the home provides enabling an informed decision about admission to be made. Assessments are carried out prior to admission to ensure individual needs can be met. EVIDENCE: Observations were made of the statement of purpose this provided information about the home enabling prospective people who use the service to make informed decisions about whether they wanted to live at Lakeside. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 10 The Statement of Purpose is currently being updated to include qualifications of current staff. All people who use the service have a full assessment of their needs carried out prior to admission to the home to ensure their needs can be met at Lakeside. The assessments of the last three admissions were seen these were detailed and informative. Care Plans are put together with people who use the service and their relatives and are signed by them. People who use the service who were spoken to confirm that discussions had taken place with them prior to coming to live at Lakeside. Outcomes of assessments are confirmed to individuals in writing following the assessment. Standard 6 is not applicable to the service. Lakeside Residential Home DS0000004968.V340737.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): Standards 7 8 9 10 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people who use the service receive is based on their individually assessed needs. A personalised plan of care is in place to meet those needs. EVIDENCE: Individual care plans have been updated into modular form that includes, Identification Sheet Doctors Visits Care Plan Health Review Risk Assessments Communication Key Worker Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 12 Daily Records Four care plans were reviewed and were detailed up to date and very informative. These care plans have been developed by the Care Manager and Deputy Manager who should be congratulated for the work they have done. Areas on healthcare records where people who use the service have allergies it is recommended that this be highlighted in an alternative colour. Healthcare needs are met by accessing local healthcare practices good relationships exist between district nurses and general practitioners visiting the home. There is a low rate of pressure areas at the home where there are individuals with pressure sores they have usually been discharged from hospital with them. Specialist medical advice or treatment is accessed via general practitioner as required to meet specific need. The inspector recommends that a protocol be put in place for nail care, as there does not seem to be anything in place to advise staff on nail care in particular for diabetes. Examination of medication administration records at 11.30 am identified that one individual had not received their 9 am medication. This was discussed with the member of staff who was administering medication who felt she had been distracted at the time. Following discussion with the Deputy Manager the medication missed was then administered, as there was no lunchtime medication due. The correct administration of medication will be a requirement of this report. The last two audits by the pharmacist were seen and identified everything as being in order. People who use the service were treated in a respectful manner with individuals right to privacy and dignity being promoted throughout this inspection. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 13 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): Standards 12 13 14 15 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Observations of people who use the service were that individuals were able to make choices about their lifestyle and are supported to maintain their life skills. Thus ensuring that social, cultural and recreational activities meet individual’s expectations. EVIDENCE: Social and recreational activities that individuals are involved in are now recorded in personal care plans. Daily living routines were observed to be flexible with individuals being observed making choices about what they wish to do. Observations were made of visitors in and out of the home, sitting in bedrooms, lounges and in the garden with individual people who use the service. Comments received from visitors were very positive about the way their relatives are cared for at the home. Comments from individuals living at Lakeside included, “Very caring staff” “Manager listens to what you say” “you can do what you like” “foods alright sometimes”. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 14 Church groups visit the home from time to time providing another interest for people who use the service. All have friends or relatives visiting them. From conversations with individuals and discussions with staff it was identified that people who use the service are still not involved in choices of what goes into the menu. Individuals the inspector was told by staff are presented with a completed menu to choose their food from. Inspector was told chef does the menu but people who use the service or the care manager at Lakeside are not consulted about the content of the menu. Lunch today portions were generous and mealtimes were observed to be flexible. Uncovered and undated food was found in the main kitchen marble cake and bread. This should be disposed of when meal is finished not left lying in the kitchen. As previously identified in reports the main industrial kitchen in this home is not used or staffed with kitchen staff. Food is transported from the other home on site via hot boxes and golf type buggy. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 15 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): Standards 16, 18 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a robust complaints procedure enabling individuals to raise any concerns they may have. EVIDENCE: As at the previous inspection the home has in place a complaints procedure that is displayed in the hallway and contained in the Statement of Purpose and Service Users Guide along with the address of the Commission for Social care Inspection. There is also a copy in service users bedroom. This is discussed with people who use the service and relatives on admission to the home. There have been no complaints received about the home since the last inspection. The registered person ensures that residents are protected from abuse via detailed policies and procedures to ensure that staff, were aware of practices to be followed in the home. Observations of staff and residents along with ongoing staff training, all form part of the protection of residents. Fifty one percent of staff has completed training on Elder Abuse and Dementia Care remaining staffs are to commence this training in August 2007. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 16 Staffs spoken with were able to identify areas where abuse could occur. People who use the service spoken with knew who to speak to if they were unhappy about something. Any allegations or incidents of abuse would be promptly followed up and recorded along with any action taken to deal with them. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 17 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): Standards 19, 26 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of this purpose built home enables people who use the service to live in a safe well-maintained and comfortable environment, which encourages independence. EVIDENCE: The location and layout of this purpose built home is suitable for its stated purpose. From inspectors observations made when walking around the building it provides safe well-maintained accommodation where individual bedrooms are personalised and homely. People who use the service who were spoken with in their bedrooms said that they were happy with the environment and Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 18 that relatives could visit them in their own bedrooms this was observed to be happening throughout the day. A rolling programme of routine maintenance and renewal takes place the ground floor lounge has just been completed and the kitchen was in the process of being completed. The home was clean and generally odour free with infection control procedures being in place. Policies and procedures are in place to inform staff of practices for control of infection and staffs spoken with were aware of these policies. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 19 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): Standards 27,28,29,30 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of staff in the home are trained and sufficient in numbers to support people who use the service, in line with their terms and conditions, and to support the smooth running of the home. EVIDENCE: As at previous inspection observations of staff identified that staff on duty were as the rota and sufficient in numbers to meet the observed needs of service users in their care. Robust recruitment procedures are in place to employ staff criminal records bureau checks are carried out along with POVA checks prior to permanent employment being offered. This information was seen at time of inspection. Ongoing staff training programme in place with records being maintained of all training attended by staff. All staff has completed mandatory training and paid to attend this. Training matrix is reviewed monthly. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 20 Observations were made of five staff files these files would benefit from tidying up as three of the files information was in admin office and had not been filed. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 21 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): Standards 31,33,35,38 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems. The Care Manager is well supported by proprietors and her line manager ensuring the health and welfare of people who use the service is observed. EVIDENCE: As at previous inspection The Care Manager has been employed on the Lakes site since 1977 and has worked at Lakeside since May 2001. She has previously worked as Deputy Manager. The Care Managers training and qualifications include the following: Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 22 Completed NVQ Level 3 February 2004 and is registered to working towards her NVQ level 4 and the Registered Managers Award which she is awaiting completion of last module. First Aid at Work Intermediate Certificate in Food Hygiene and Safety Manual Handling Competent Person Strokes Health call Optical Awareness Appreciation of Dementia Managing Aggression Safe Administration of Medication Infection Control Prevention of Pressure Sores Rosemont Duty of Care The Care Manager has previously worked for Social Services on community care and has also worked in nursing homes on night duty. She has dealt with staff supervision, appraisals, and provided and supported staff through training and is competent to manage the home. The home is run with interests of service users first regular discussions take place with individuals. The Care Manager listens to service users views and ensures where possible requests are implemented. Finances of people who use the service were sampled, cash balanced with records maintained. The registered proprietors and care manager ensures so far as is reasonably practicable the health safety and welfare of service users and staff. Regular supervision of staff is carried out both formally and informally the management operating an open door policy. An experienced competent Deputy Manager has now been appointed to deputise for the Care Manager and this is working very well. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 23 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13(2) Requirement The registered person shall make arrangements for the safe administration of medicines. Ensure that all medications are administered and signed for by staffs that are trained to do so. 16/07/07 Timescale for action 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. 4 Refer to Standard OP1 OP8 OP8 OP15 Good Practice Recommendations Complete the updating of Statement of Purpose and forward copy to CSCI Allergies on care records be highlighted in alternative colour A protocol for nail care be put in place including for diabetics Uncovered and undated food should be disposed of when meal is finished not left lying in the kitchen. Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 25 5 OP8 Records of doctors visits be more detailed and include why called diagnosis and treatment prescribed Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Local Office Dyson Court Staffordshire Technology Park Beaconside, STAFFORD ST18 0ES 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 Lakeside Residential Home DS0000004968.V340737.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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