Inspection on 12/12/03 for Waters Edge Care Home

Care Home For Older PeopleLakeside Residential HomeAlpha Healthcare Ltd Croft House Moons Moat DriveAnnounced Inspection12 December 2003 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Lakeside Residential Home Address Hardwick Care Village, Stafford Road, Great Wyrley, Walsall, West Midlands, WS6 6BA Email Address Name of registered provider(s)/Company (if applicable) Ralton Care Homes Limited Name of registered manager (if applicable) Miss Julie Michelle Hinton Type of registration Care Home No. of places registered (if applicable) 63 Tel No: 01922 409898 Fax No:Category(ies) of registration, with (number of places) Dementia - over 65 years of age (4), Mental Disorder, excluding learning disability or 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) Registration number E090000160 Date First registered Date of latest registration certificate 6th June 2002 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspection 30th December 2002 YES YES 9/6/03 If Yes Refer to Part CLakeside Residential HomePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector 112 December 2003 09:00 am Mrs Kathryn MarksID Code075892Mrs W D Grainger Name of Inspector 2 Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Julie Hinton the time of inspectionLakeside Residential HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with additional conditions of registration (if applicable) Providers Response Providers comments Action Plan Providers Agreement Signature Mrs Kathryn Marks Second Inspector Mrs W D Grainger Locality Manager Date Public reports It should be noted that all NCSC inspection reports are public documents. 20 May 2004 Signature SignatureLead InspectorMrs Kathryn Marks Mrs W D GraingerLakeside Residential HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Lakeside Residential Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Lakeside Residential HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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 HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Lakeside Residential HomePage 6 This inspection took place over one day on Friday 12 December 2003 two Inspectors carried out the inspection. The Inspection found that the majority of National Minimum Standards were met and that generally the quality of care was good. Observations of service users surveys carried out at the home were that the negative comments all related to food. Inspectors walked around the home, the majority of service users were spoken to and comments made by individuals about the care they received were positive. Choice of Home (Standards 1-6) 4 of these 6 standards were inspected The home has in place a Statement of Purpose and Service users Guide both of which need to be updated to provide all information identified in National Minimum Standards. All service users have contracts of their terms and conditions of residence at the home, and all have an assessment of their needs carried out prior to admission. Standard 1 was not met both Statement of Purpose and Service Users Guide must be updated, Standards 2 to 5 were met, Standard 6 is not applicable to this home. Health and Personal Care (Standards 7-11) 5 of these 5 standards inspected there was a requirement for Standard 9 and therefore received a two on the score. Arrangements were in place for meeting the health and personal care needs of service users. Service users have individual care plans that are detailed and highlight identified health care needs. Where appropriate service users are able to self medicate and a secure facility is provided for the storage of their medication. There was a requirement to formalise the recording for the prescribed controlled medication to prevent any errors . Individuals spoken with confirmed that their privacy and dignity is promoted and they are treated with respect. Daily Life and Social Activities (Standards 12-15) 4 of these 4 Standards were inspected Standard 15 did not meet the requirements and therefore received a one on the score. The home had employed two activity co-ordinators for Lakeside, the service users were provided with a weekly event sheet outlining the activities. Records were maintained of the activities service users had taken part in. Service users were asked their preference/interests during the admission process. Visiting policies were flexible; this was evidenced during this inspection with many visitors entering the home. They expressed to the Inspectors that they were always made to feel at home by the staff and management. Each of the families had been provided with the code for the digital door to gain access. Spiritual needs were recognised and respected, arrangements were in place for the service users to receive their minister/priest. The inspectors were told that the service users had requested a meeting; this would be Lakeside Residential Home Page 7 facilitated in 2004. The inspectors were asked to speak to service users who made a complaint, supported by the evidence of the meal served to them during the Inspection. The fish was inedible, being cooked and stored for too long in a hot trolley. The catering is done in the larger house and transported across. The complex has approximately 200 service users and all food is prepared in the one kitchen in the morning. Lakeside has a fully fitted kitchen, which is not used. This was fully discussed with the management. The inspector had concerns that there were limited resources of food left out for the evening/night time for the service users. There was a need to review the quality and quantity of the cutlery provided. Complaints and Protection (16-18) 3 of these three Standards were inspected and met The Commission had received no formal complaints since the previous inspection. The care manager had not found it relevant to investigate any concerns from the relatives or service users since the last inspection. The care manager was fully aware of the action to take in the event of an allegation of abuse made against the service users. The inspectors were satisfied from the records that the service users civic and legal rights were protected. The management would arrange for postal voting. Finances were not handled by the management this was the responsibility of the service users or their families. The home had robust policies and procedures in place to protect the service users from abuse. Environment (Standards 19-26) 8 of these Standards were inspected and met The management and staff maintained high standards of hygiene and should be congratulated. The purpose built home was designed to provide accommodation to older people. The corridors were wide for easy access. Each of the bedrooms had an en-suite facility; located throughout the home were separate toilets and bathrooms; each clearly identified. The laundry was located at the end of the home and was operated on a daily basis. A rotary iron had been recommended on the last inspection, this recommendation had not been taken on board by the provider. Each of the floors mirror imaged the other, each one having a smoking lounge and various other areas for the service users to relax in. Corridors were wide and fitted with hand rails, grab rails were fitted in the toilets both ensuite and communal. The staff were made aware of the importance of cross infection via training and being provided with the appropriate protective clothing.Lakeside Residential HomePage 8 Staffing (Standards 27-30) 4 of these 4 standards were met The home is staffed with employees who are experienced and competent to care for older service users. The home has in place recruitment policies and procedures to ensure that staff are appropriately recruited and interviewed. There is a three months induction and a staff-training programme to ensure staff are trained to do their job. Management and Administration (Standards 31-38) 8 of these 8 (Standards were met) The home is run by a person who is experienced and competent who involves service users in discussions about what is happening in the home. Lakeside has now developed a Quality Assurance system that is audited yearly. Areas of administration examined were detailed and up to date.Lakeside Residential HomePage 9 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for actionAction is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Lakeside Residential HomePage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action The statement of purpose must identify to service users that escorts do not always accompany individuals attending hospital. 2 Months from the date of inspection 2 Months from the date of inspection14 (1)OP12OP1The service users guide must include all areas identified in Standard 1.2 of the National Minimum Standards It was required that the management formalise the recording system for any controlled drugs prescribed to the service users. To monitor the food served to the service users, meals should be wholesome and nutritious properly prepared at all times. It was required that the provider considers employing catering staff for the main kitchen at Lakeside. There should be a selection of food available to the service users at all times including nights. To review the quality/quantity of the cutlery provided.313 (2)OP92 2 04416 (i)OP152 2 04Lakeside Residential HomePage 11 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * Consideration should be given to the deployment of domestic staff to give cover at tea-time thus avoiding care staff coming off care duties to deal with tea. .1OP27* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Lakeside Residential HomePage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES 55 12 0 YES YES YES YES 41 0 12/12/03 0900 14Lakeside Residential HomePage 13 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Lakeside Residential HomePage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 294.58 To (£) 333.00Any charges for extrasYESHAIRDRESSING PRIVATE CHIROPODYIf yes, please state what the extras are: 1 Key findings/Evidence Standard met? The home has in place a Statement of Purpose to inform service users of aims, objectives, and services/facilities provided at the home. Information given to Inspectors by the Care Manager was that escorts are not always sent with service users who have to go to hospital. The homes Statement of Purpose should be updated to include this and will be a requirement of this report. The service users guide should also be reviewed and updated to include all information identified in Standard 1.2 of the National Minimum Standards and will be a requirement of this report. All service users and their relatives have been given information on how to contact the National Care Standards Commission.Lakeside Residential HomePage 15 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? On moving into the home service users are issued with a statement of their terms and conditions or contract if purchasing care privately. Terms and conditions include rooms to be occupied, care and services provided, fees and additional charges, rights and obligations of the service user and provider, conditions of occupancy and period of notice.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? Service users are admitted to Lakeside Residential Care Home, following a full assessment of their individual needs by appropriate persons as at the previous inspections. The Care Manager and her Deputy would be involved, the service user and their relatives, the district nursing service, general practitioner, and any other appropriate professional person who had been involved with the service user in the community or their current situation. Following admission the staff at the home would then complete their own assessment of needs and a care plan would be produced. This would involve the service user and their relative and be agreed by them. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The registered person is able to demonstrate the homes capacity to meet the assessed needs of service users via pre-admission visits, on-going assessments, and verbal discussions with service user and professionals involved with the individual. Detailed care plans that identify clearly what staff need to be doing to meet the identified needs. Two service users were case tracked, care plans and any other written information relating to them was observed and both individuals were spoken with. All specialist services offered are based on good practice, staff training, liaising with outside organisations and accessing professional advice.Lakeside Residential HomePage 16 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? As at the previous inspection, service users prior to admission are invited to the home for a short visit, overnight stay or whatever the prospective service user wishes to do before making a decision to move into the home. All are admitted on a trial basis before the service user makes a decision to stay permanently at Lakeside. The home does not generally take unplanned or emergency admissions. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard has not been inspected the home does not provide intermediate care.Lakeside Residential HomePage 17 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? Following admission to the home and assessment of needs being completed the service users plan of care is produced this involves the service user and is signed by them or their relatives. The plan identifies the action to be taken by staff to ensure the health, personal and social needs of the individual are met. Observations were made of risk assessments on file with attention being paid to the prevention of falls. Reviews of care plans take place monthly with a detailed three monthly review. There were no service users who were subject to requirements of the Mental Health Act 1983.Lakeside Residential HomePage 18 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)16 53 Key findings/Evidence Standard met? The registered person ensures the health care needs of service users are met. Where possible individuals remain with their own General Practitioner if he will visit them at the home, if not then a choice of GP in the area is provided. All service users are encouraged to be independent with oral hygiene with help being available as required. The district nurse/continence advisor assesses individuals felt to be at risk of developing pressure sores and appropriate action is taken. There are currently five service users with pressure sores and these are being dealt with by the district nurse, nursing notes were seen. Lots of room within the home for individuals to walk around and externally there are level walkways for individuals to exercise. Music and movement take place along with gentle exercises. Specialist medical services are accessed as required. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? Policies and procedures were in place for the management of medication and to inform staff of practices to be carried out in the home. Staff spoken to, were familiar with these policies and discuss them during supervision. No one is currently choosing to self- medicate. All service users do have a lockable facility in their bedrooms for the safe storage of medication or valuables. Medication Administration Sheets were examined and found to be up to date. All medications including controlled drugs are appropriately and securely stored. The records for the controlled medication were confusing with two recording systems being used; it was required that the staff formalise the records to ensure that their can be no errors when administering the medication. All staff administering medication have been trained to do so.Lakeside Residential HomePage 19 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Discussions with service users and observations during this visit confirmed that the privacy and dignity of individuals is respected with principals of care being promoted. The district nursing service visits the home regularly positive action was observed between district nurses and staff at the home. Visiting nurses the Inspectors spoke to were positive in their comments about the manner care is delivered at the home. There is a telephone situated in the vestibule at the bottom of the staircase, this staircase is only used occasionally so does provide a relatively quiet area for service users, the office telephone is also available for individuals to use. When being visited by their General Practitioner or the district nurse consultations take place in service users own bedrooms. The home has four shared bedrooms all have privacy screening. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Policies and procedures are in place for handling death and the dying, staff spoken with were aware of these policies. Observations of letters and cards from relatives of deceased service users and discussions with staff confirmed that care and comfort are given to individuals who are dying. Pain relief is accessed via general practitioner to meet the needs of the individual and constantly kept under review. Service users families are involved in planning for death if that is what the individual wishes to happen. All service users are able to spend their final days in their rooms unless there are strong medical reasons for not doing so. Relatives and friends who may wish to remain with a service user who is dying would be made comfortable and hospitality offered.Lakeside Residential HomePage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? The management had appointed two new activity co-ordinators since the previous inspection; they will be responsible for Lakeside activities. It was their responsibility to ensure that some form of activity took place daily. Each week an information sheet of the planned activities was given to all the service users to make their personal choice. The service users interests were recorded on admission; a record was maintained of the activities service users took part in. Spiritual needs were recognised and respected, arrangements were in place to ensure that all the present service users faiths were addressed. The homes management had planned seasonal entertainments. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? The care manager told the inspectors that the visiting policy was very flexible; this was evidenced during the inspection. The code for the digital door was provided to each family member. The care manager would respect the service users wishes to see any person they choose to. Each scenario would be reviewed on an individual basis when necessary. The Service Users Guide contained the information in respect of visiting, although there were no restrictions.Lakeside Residential HomePage 21 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? The inspectors were satisfied that the service users were encouraged to be independent with their personal finances. The management did not handle finances on behalf of the service users. Where necessary the families would take responsibility. The service users have requested a meeting with the management; this would be in the New Year. The deputy care manager would ensure via documentation that all the families would be informed of how to contact external agents if necessary. Many of the bedrooms sampled at the time of the inspection contained personal possessions. The personal records/files of the service users were stored appropriately; confidentiality was part of the homes induction programme.Lakeside Residential HomePage 22 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 1 Key findings/Evidence Standard met? Lakeside had a dining room on each floor; they were bright with plenty of natural light from the large windows. Some service users prefer to remain in their bedrooms where the staff were observed to serve them. Each floor had a small kitchenette where light snacks, hot & cold drinks were prepared. Ten of the service users sugar content dietary requirements were monitored. Four of the service users were served a softer diet. One service user on the ground floor required assistance when dining. Within Lakeside there was a fully fitted kitchen, this registered area was not operational, food was prepared and cooked at the larger establishment and transferred by a golf trolley to Lakeside. The Inspector reviewed the area, it was identified to the management that there were limited provision of food in the event of a service users requesting a cheese sandwich during the evening no provision had been made for this. The meal on the day of the inspection was breaded plaice, parsley sauce, and chipped potatoes, mushy peas followed by a Madeline sponge. There was no evidence of parsley sauce seen on the meals observed. The inspectors received a number of verbal complaints and were asked to visit one of the service users in his room. The inspector was presented with a hard piece of fish across the top of a dish; the fish would not bend into the dish. The service user and others had been served fish in this in-edible condition. Other comments from service users were that the teatime sandwiches were dry with hardly any filling. The condition of the meal today was brought to the attention of the general manger who was in the home. The solution to reducing the inedible food being cooked so early and served due to the amount of service users in both homes approx 200 was to employ catering staff and to open Lakeside kitchen. The inspectors were provided with lunch of their choice, served in one of the lounges. The cutlery provided had pieces broken from the handle. It was required that the cutlery provided was reviewed and appropriate and sufficient cutlery was provided.Lakeside Residential HomePage 23 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and those complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated 0 0 0 0 No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 0 0 0 3 Key findings/Evidence Standard met? The home displayed the policy for making a complaint within the front entrance. The Commission had received no complaints since the last inspection. The management told the inspectors that no formal complaints had been made to the home.Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The Inspectors were satisfied that the management and families protected the service users civic and legal rights. Where necessary postal votes can be arranged. Each of the service users were registered on the electoral role.Lakeside Residential HomePage 24 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The majority of the staff had NVQ level II. Some further training had been provided to ensure that service users were protected against abuse. The care manager would follow the policy and procedure for the home in the event of any allegation of abuse being reported to her.Lakeside Residential HomePage 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Lakeside was purpose built to provide care for older people, located along the side of the busy A34 leading to Bloxwich and Walsall. The home was suitable for its purpose. The home had a level patio area surrounded by lawns. There was a routine decorating and refurbishment programme. The home did not have CTVV cameras around the home. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? All areas with the exception of the laundry and kitchens were available to the service users. The home provided for any service user that chose to smoke with a separate lounge on each floor. The furnishings and fitting throughout the home were well maintained. Corridors were wide and made access easy for the service users.Lakeside Residential HomePage 26 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Each of the bedrooms had an en-suite facility; bedrooms were seen to have personal possessions. The service users had access to the communal toilets and bathrooms located throughout the home, each one was identified for the benefit of the service users. Lakeside had a number of assisted bathing facilities located on both floors. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Lakeside had wide corridors fitted with hand rails; grab rails were fitted in the toilets both ensuite, communal and bathrooms. The home was registered two years ago; some service users had been admitted to the home with their personal equipment i.e. walking frames and walking sticks. Where necessary the management can access people that were qualified to assess for equipment for the communal use within the home. The service users call system was audible during the inspection and answered promptly.Lakeside Residential HomePage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 0 55 4 4 55 013 0 4 03 Key findings/Evidence Standard met? There had been no changes to the bedroom sizes since the previous inspection. Bedrooms were to the required size and complied with the National Minimum Standards.Lakeside Residential HomePage 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? The home provided accommodation that was well maintained both in hygiene and furnishings. The staff worked hard to maintain this high standard. The home was warm and had a comfortable atmosphere. Bedrooms seen during the tour of the premises evidenced many personal possessions. Each of the service users were provided with a lockable facility for valuables/medication. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The style in which the home was built provided plenty of natural light from the large windows. Lighting was domestic in style and the home was warm and comfortable. Radiators were of the low temperature type. Testing of the water system continued, records were maintained.Lakeside Residential HomePage 29 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The premises were maintained to high standards throughout. The laundry was located on the ground floor and operated daily. A recommendation that the laundry was fitted with a rotary iron had not been addressed. It is important that the laundry staff had the appropriate equipment to complete their job. To prevent pressure areas it is important that linen was ironed. Gloves and aprons were provided to the staff to prevent the spread of infection.StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 9 220 0 needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses 29 20 0 No. staff hours allocated No. staff hours allocated No. of staff hours provided 396 368 1078 0 0 00Lakeside Residential HomePage 30 No. of care staff No. of ancillary staff Key findings/Evidence41 0 Standard met? 3Observations during this visit were that the staffing numbers and skill mix of staff were meeting the assessed needs of service users in the home. The staffing rota identified the following shift pattern this being the usual staffing for this home with the exception of the Care Manager and Deputy who would normally work opposite shifts: Care Manager 9-4.30 pm Deputy Manager 9-4.30 pm 2 Care Assistants 7 am- 2pm 6 Care Assistants 8am ­ 2 pm 7 Care Assistants 2 pm ­ 8 pm Night staffing is covered by 6 waking watchful night care assistants one of whom would be a senior care. 6 Domestics all start at 8am 3 finish at 12 midday, 3 finish at 2pm. Deployment of domestics should be reviewed to give cover at teatime to avoid care staff coming off care duties. Handy person 9-2. The current arrangements for catering at Lakeside were that cooking staff are based at Hardwick Court and meals are brought over to Lakeside. This arrangement was agreed on a trial basis when the home first opened. Feedback today from service users is that the arrangement is not working. Service users said sandwiches are dry and individuals are not able to have late choices met. Staff said they are being told by chef we have to cater for 200. Lakeside has its own full sized kitchen that was registered at the same time as the home in July 2001. Serious consideration should be given to employing a chef/cook for Lakeside and the kitchen become independently operational in this 63 bedded home separately registered from Hardwick Court and separately staffed apart from this arrangement.Lakeside Residential HomePage 31 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 20 50 3 Key findings/Evidence Standard met? The home meets the minimum ratio of 50 of staff trained to NVQ Level 2 or above and NVQ training is part of the homes ongoing staff-training programme. There are no trainees at the home at this time should the situation change then they will be registered on a TOPPS certified training programme.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The home operates a recruitment programme based on equal opportunities recruiting staff via the local job centre and newspaper. Written references are taken up and Criminal Records Bureau checks are carried out before confirmation of appointments. The home has now obtained copies of the General Social Care Council Code of Conduct and Practice and copies of the code have been given to members of staff. All staff had copies of their terms and conditions of employment. The home does not recruit volunteers should the situation change then staff are aware of the procedures to be followed. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The registered person has in place a staff training and develop programme working with TOPPS to ensure that this meets National Training Organisation workforce training targets. All staff received induction and foundation training working through a three months induction booklet. All staff have a training profile and receive three paid days training a year.Lakeside Residential HomePage 32 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The Registered Manager of the home has 16 years experience in care work and has been a manager since February1998. Lakeside opened in May 2001 and The current manager was recruited prior to the home opening. She has NVQ Level 3 & 4, D32 &33 Assessors award, she is trained in moving and handling, fire safety, health and safety, first aid, and food hygiene. The Registered Manager is responsible for Lakeside Care Home only. The manager and senior staff were familiar with and able to discuss diseases associated with old age. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The management approach at the home was observed to encourage both staff and service users to freely seek advice and guidance or just come to the office for a chat if they wished. Service users were observed to be moving freely around the home during todays inspection with positive interaction taking place between staff and service users. Communication in the home was good with both staff and service users knowing who to relate to. The General Social Care Council Code of Conduct and Practice is in place at the home and all staff had been issued with a copy of the code.Lakeside Residential HomePage 33 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? Policies and procedures are in place for quality assurance, the Care Manager and Deputy having developed quality audit systems for the home. The home has in place an annual development plan this is based on planning and reviews for service users. Service users surveys are carried out and a sample of surveys will now be included in the service users guide. Feedback is received from service users via surveys, discussions with individuals, and via care plan reviews. Verbal feedback is sought from relatives and friends of service users. Individuals were aware that an Inspection was taking place today. All policies and procedures are currently being reviewed and updated to ensure compliance with National Minimum Standards. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? As at the previous inspection the Care Manager told Inspectors that the home was financially viable. Insurance cover is in place against loss or damage to assets of the business, business interruption costs and public liability. Records are kept of all transactions entered into by the registered person and there is a business and financial plan for the home.Lakeside Residential HomePage 34 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 1 0 03 Key findings/Evidence Standard met? The registered manager ensures that service users who wish to are able to handle their own finances one service user is currently doing this. A secure facility is provided in the service users bedroom for safe storage of valuables and monies. Remaining service users finances are dealt with by individuals and their families or management at the home. Written records are in place for all transactions carried out, cash balanced with records maintained. The Registered Manager is not the appointed agent for any service user. Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? The Registered Manager ensures that policies and procedures in the home are put into practice these are discussed at supervision and during staff meetings. Staff supervision is carried out on a formal basis at least six times a year covering practice in the home, philosophy of care and career development needs. The home does not use volunteers should the situation change staff are aware of the procedures to be followed.Lakeside Residential HomePage 35 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Records for the home required by regulation are in place and were sampled. Service users spoken to knew that records relating to them are maintained and that they could access these records if they wished to do so. All records were securely stored and those records that were sampled were accurate and up to date.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The registered manager ensures as far as is reasonably practicable the health, safety and welfare of service users and staff. Safe working practices are carried out staff had received training in moving and handling, fire safety, first aid, food hygiene, and infection control. Hazardous substances are safely stored and regular servicing of equipment and systems is carried out. The registered manager ensures compliance with relevant legislation and ensures that risk assessments are carried out for safe working practices. All staff receives induction and foundation training.Lakeside Residential HomePage 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition 10 PD(E) 6 may be PD over 55 years CommentsComplianceYESCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLakeside Residential HomePage 37 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 12 December 2003 and any factual inaccuracies: Please limit your comments to one side of A4 if possible A copy of the providers comments and action plan are available at the Area Office, where these have been submitted.Lakeside Residential HomePage 38 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 31 March 2004 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Lakeside Residential HomePage 39 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Lakeside Residential HomePage 40 - 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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