Inspection on 11/10/06 for Waters Edge Care Home

This inspection was carried out on 11th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 10/07/07

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

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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 Key Unannounced Inspection 11 October 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lakeside Residential Home DS0000004968.V311893.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.V311893.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 (4), 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.V311893.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 17th January 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. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this inspection on the 11th October 2006. During the course of the inspection and via feedback questionnaires positive comments were received from residents and visitors about the home. Residents indicated during conversations with them that generally they were happy with the manner in which services are provided to them and care is carried out in the home. The Care Manager via discussions with her and observations of the preinspection questionnaire provided information regarding staffing, staff training, menu and dietary provision that was observed by the Inspectors to be in place at the home. On arrival at Lakeside individuals were in different areas of the home some completing breakfast others in lounges chatting and the hairdresser was present today. Resident’s accommodation is located on the ground and first floor observations of the Inspector were that the home was generally clean and comfortable there were areas that were awaiting cleaning but this was dealt with why inspectors were at the home. Resident’s bedrooms were individualised with favourite personal items they had brought into the home with them. Lakeside has in place a statement of purpose and service users guide to inform individuals of the services and facilities provided. This is being updated to include the 3-day care places. All residents have a full assessment of their needs carried out prior to admission to the home and the last three assessments were seen. As previously arrangements are in place for meeting the health and personal care needs of residents and details are recorded in care records. A variety of social opportunities are available for individuals who wish to be involved including service users with dementia. The home has a complaints procedure in place that residents were aware of and is given to them on admission to the home. The complaints procedure is also displayed in the home along with details of how to contact the Commission for Social Care Inspection. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 6 Staffs at the home are experienced and competent to care for older people and were able to discuss diseases associated with old age. Appropriate recruitment procedures were in place and all staff prior to employment has Criminal Records Bureau and Pova checks carried out via human resources at Lakeside. What the service does well: What has improved since the last inspection? 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. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. Standard six is not applicable to the home. 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 User Guide providing residents and prospective residents/carers/relatives with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: A full assessment of individual needs is carried out prior to admission to Lakeside. No resident would be admitted to the home unless a full assessment of his or her needs had been carried out to ensure needs can be met and the outcome of the assessment confirmed in writing to the individual. The home has in place a Statement of Purpose and Service users guide that is being updated to include the 3-daycare places. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is poor. This judgement had been made using available evidence including sampling the care plans, reviewing the medication records and practice, and observation of the staff on duty. The residents could be at a potential risk from the medication practice evidenced. The sample of care plans identified that they could be further developed by reviewing the risk assessments. EVIDENCE: The sample of care plans were discussed at feedback, the reports were meaningful and identified changes in the individuals health needs. One of the care plans was in need of a current evaluation. The system used for evaluations differed between floors. It was recommended that the staff identify the day of evaluation and not just the month. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 10 Each of the plans seen had basic risk assessments from the information of planned care there were elements that were not covered in the risk assessment section. It was required of the care manager that the risk assessments were reviewed. Arrangements were in place for the continued health care needs to be met by other professional agencies. During the inspection a general practitioner and two district nurses were spoken with, each one had only complimentary things to say about the staff who responded to the instruction left at any one visit. The care manager had implemented a controlled drug audit and a general medication audit. The controlled drug audit was checked and found to correspond to the records. The inspector had concerns that eye medication for both floors had not been dated when opened. Two separate members of the staff had signed and administered out of date eye medication. The system used by the home had failed. Identified in the medication sheet sent by the pharmacy recorded “as directed by the provider” this should not have been accepted and action to clarify the dose required should have been implemented by the senior staff receiving the medication. This concern will be a requirement for this report. The staffs on duty were polite, respecting the daily routine of the residents. They were seen and heard to welcome visitors. A visitor spoke highly of the staff and their commitment to their role as carers. She welcomed the freedom to make drinks. Each of the residents seen at the time of the inspection was well dressed. Residents told the inspector that they liked living at the home the staffs was “very good to them”. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including speaking to residents, observing the daily menu and lunch, reviewing the activity programme. The menus of the day were observed. Meals were transported in an appropriate container from the larger home on the complex and main kitchen. Visitors were welcome to the home at any time suitable to them. EVIDENCE: The activity programme record was well maintained, the staff work together as a team to provide a variety of activities. At the time of the visit “skittles” had been played, it was planned to do an alternative activity in the afternoon. There was evidence from the care plans and activity records that residents with dementia were part of the social stimulation. It was discussed at feedback that perhaps the staff could identify “Art & Craft” sessions more clearly. Within the entrance there were notices of entertainment that was purchased for the home from other sources. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 12 The meals were prepared within the larger home on the complex then transferred to Lakeside. Comments regarding the food were positive. The meal of the day was observed, some residents had chosen the alternative of the day, spaghetti. The ground floor fridge seal had split the base where dried milk had been spilt needed cleaning. The inspectors were told that a replacement fridge was to be delivered the following day. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, observation of complaints records and discussions with the Care Manager and Service Users. 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 residents 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. All staff are attending training on Elder Abuse next week for some staff it’s a refresher course new staff its their first course. Communication training is also being carried out at the home. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 14 Staffs spoken with were able to identify areas where abuse could occur. Service users spoken with and feedback questionnaires evidenced that individuals knew who to speak to if they were unhappy about something. Any allegations or incidents of abuse would be promptly followed up and recorded. Policies and procedures are in place to inform staff of practice at Lakeside and a training session on Whistle Blowing policy is to be carried out at the home. The human resource dept for the company will be involved. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and observations made during a walk around the home. EVIDENCE: On a walk around the home it was observed that service users individual bedrooms were pleasant and contained personal possessions. Included in the tour of the home was the laundry, the management had taken on board the advice given on the previous inspection, it was evidenced that the precautions for infection control was operational with the use of alginate bags for soiled linen. There was a need to monitor the fitment of the bed guards “cot sides” to ensure that they were fitted correctly. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 16 The audit recommended in the previous inspection to monitor the ferrules on walking frames was in the process of being implemented. There had been a change of handy personal, this will be part of his remit. The large dining room at the home had been changed into a lounge diner for a small number of residents. The smaller lounge following discussion with service users was now the dining room. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. As at previous inspections staff on duty at Lakeside was observed to be competent. Appropriate procedures are in place for the recruitment of staff. 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. 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.V311893.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. The Manager is well supported by the proprietors and her Line Manager in providing clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. Ensuring the Health and Welfare of residents 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: Completed NVQ Level 3 February 2004 and is registered to working towards her NVQ level 4 and the Registered Managers Award which she completes December 2006. First Aid at Work Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 19 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. The home is not involved in resident’s finances these are managed by residents/relatives and solicitors. 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. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 20 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 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 2 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.V311893.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation Requirement Timescale for action 2 OP9 13 (4)( c ) The registered person shall ensure that unnecessary risks to 24/11/06 the health of the residents are identified and so far as possible eliminated. Risk assessments should reflect individual’s requirements. 13(2) The registered person shall make arrangements for the safe 24/11/06 administration of medicines including the dating of medication with limited use. 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 OP7 OP1 OP12 Good Practice Recommendations To date the evaluations on the monthly care plans. To include the 3 day care places in statement of purpose. (This is inspector understands being dealt with.) To clarify more clearly what was included in the art & craft sessions. Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lakeside Residential Home DS0000004968.V311893.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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