Inspection on 31/08/05 for Waters Edge Care Home

This inspection was carried out on 31st August 2005.

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 10/07/07

Waters Edge Care Home 11/10/06

Waters Edge Care Home 17/01/06

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 Kathryn Marks Announced 31 August 2005 9:00 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 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 E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 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 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 Ltd Mrs Sandra Potts CRH 63 Category(ies) of DE(E) - 4 registration, with number MD(E) - 6 of places OP - 63 PD - 6 PD(E) - 10 Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 3) 6 may be physical disability minimum age 55 years on admission Date of last inspection 19 October 2004 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. Resident’s 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. There is a new Care Manager and Deputy Manager in post who were observed to have developed a positive working relationship. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day on 31st August 2005. Prior to the Inspection the inspecting officer received responses to five comments cards two from residents and three from relatives. Comments were mixed two service users raising issues regarding food that were fed back to the care manager and her deputy, two more residents raised issues relating to food when walking around the home chatting to them. The care manager is dealing with these issues. Positive comments were also made in comments cards and provided written evidence that residents who had responded were satisfied with the manner in which services are provided to them and care is carried out in the home. Care Manager provided written information regarding staffing, staff training, menu and dietary provision that was observed by the Inspector to be in place at the home. On arrival at Lakeside individuals were completing breakfast some had breakfast in their bedrooms others had come down to the dining areas when they were ready. Residents spoke highly of the staff, their care and attention when attending to personal needs. The registered care manager and her deputy were spoken of warmly. Residents felt that they were doing a good job and had moved the home forward since taking over. Resident’s accommodation is located on the ground and first floor observations of the Inspector were that the home was clean and maintained to a very high standard. 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 residents of the services and facilities provided. All service users have a full assessment of their needs carried out prior to admission to the home. Arrangements are in place for meeting the health and personal care needs of residents and details are recorded in care records. Regular social opportunities are available for individuals who wish to be involved. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 6 The kitchen is a registered facility and inspectors feel that if used on a full time basis instead of food being transferred from Lakeview it would offer residents a more flexible choice with regard to meals and mealtimes. 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. Staff 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. What the service does well: What has improved since the last inspection? • • • • Care plans as identified above Medication records due to regular audits by management Health care providers to the home have changed and are providing an improved service. Permanent maintenance person has now improved the maintenance provision at Lakeside Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3. Standard 6 is not applicable at this home. The homes Statement of Purpose and Service Users Guide provides prospective residents with details of the services the home has to offer enabling an informed decision about admission to Lakeside to be made. EVIDENCE: The homes Statement of Purpose and Service Users Guide is given to residents and relatives clearly describing the services and facilities the home is able to offer. All residents have contracts of terms and conditions of residence at the home a copy of which is on resident’s files. A full assessment of individual needs is carried out prior to admission to Lakeside to ensure that the needs of residents can be met. The prospective resident or their relative would visit the home where possible and staff would visit the individual in their own home or current surroundings. The outcome of the assessment is confirmed to individuals in writing. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7,8,9,10. Each person had a well-formulated plan of his or her care needs. The plans would be further enhanced following the review of the risk assessment document. Arrangements were in place for the continued care of residents by other professional agencies where necessary. Lakeside had a good system for the administration of medicines; EVIDENCE: Each of the care plans sampled were well formulated, there was evidence of pre admission assessment being undertaken. Records evidenced that other agencies where necessary were involved in the health care of individuals. There was a recommendation for the staff to review the risk assessment documents. Staff clearly identifying the risk, action to be taken needs to be more clearly identified. Care plans need to evidence that residents and or their representative had been involved in the setting up of the plans. A signature of the resident or relative can address this. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 11 There was a need to ensure that either the care plans or medication records identified the resident with a photo. A very small minority of residents were not prescribed medication but had a photo on the medication record, not the care plan. There was a need to ensure that at any time a cot side was required that a full risk assessment was conducted prior to fitting the equipment. The staff had policies and procedures for the administration of medicines. The general practitioner had agreed the homely remedies policy. Signatures of the staff were maintained. A small minority of the residents choose to self-administer their prescribed creams. The records evidenced a risk assessment. The records for medication maintained in a secure cupboard were accurate. There was a need to monitor the medical fridge for cleanliness. Each resident spoken with during the inspection felt that they were treated with respect. The residents spoke highly of the staff and their commitment to their care. The inspector observed the staff dealing with one resident who required assistance this was dealt with in a sensitive manner. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12,13,14,15. Each person at the home was offered a varied activity programme to choose from. Contacts were maintained with the community, families and relatives visitors were constantly in and out of the home and invited to all activities taking place. The kitchen is a registered facility, if operational full time Inspectors felt this would offer more choice to residents and the staff would take pride in the cleanliness of kitchen. EVIDENCE: Residents at Lakeside were offered a varied activity programme. Records evidenced from February 2005 identified that the social opportunities had included entertainment from outside people, trips into the community and public houses, shopping into the local town of Cannock, the local theatre was visited, VE day was made special as was the BBQ, and the garden party that raised over £500 for the comforts fund. Further planned events include fireworks with hot dogs, trips to the local school, plus a Christmas party with entertainment. The staff maintained records of peoples involvement based on the interests of individuals. Due to a sudden illness the up to date records were unavailable on this visit. The inspectors have on other visits evidenced the records. Staff Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 13 recognise that certain residents choose not to be involved in any form of activity/interest. During the inspection it was obvious that families were made welcome, visiting during the morning. Relatives independently operated the digital door lock, leaving the staff to care for residents. The inspectors had concerns within the kitchen area. This is a registered facility of the home, not used as a permanent facility. The chef based in the Lakeview home and main kitchen could not provide information as to the length of time fat had been left in the deep fat fryer at Lakeside. This piece of equipment was leaking fat and in a poor condition. The large chest freezer and the small fridge were in need of cleaning. The seal on the small fridge has split and needed replacing. The outside kitchen door was wedged open allowing for any insect/fly/wasp entering. The chain door curtain had been taken down waiting for the appropriate screen to be fitted. The cloths used by the staff after removing items from the dishwasher were in a very poor hygienic condition being very discoloured, the wire pan cleaner had fat congealed in it and the ”J” cloth was stiff and kept in a dirty container. These issues were brought to the attention of the chef at Lakeview by phone. Also discussed with the care manager and the area manager at feedback. Comments made on the cards returned to the Commission were varied in respect of the food provided. The care manager had arranged for one resident who did not complete a comments card to meet with the chef regarding more choice. The inspectors were aware that this type of meeting had been arranged before. The resident told the inspector he was not hopeful of any change. The menus were varied but did not offer a positive choice for an alternative. This was not to imply that alternatives were not available only the content of the alternatives. This was discussed at feedback. The inspectors had concerns as to the transporting of the food taken from the heated trolley and taken to bedrooms on another trolley. The dessert dishes seen today were uncovered and being taken along a carpet used every day by staff, residents and visitors. Staff had protective clothing on but this did not cover trousers that may have brushed against a toilet or bed/bath during the morning. This report made a requirement that the kitchen and food concerns were dealt with. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16,18. The home has a satisfactory complaints system with some evidence that service users views are listened to or acted upon. EVIDENCE: 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. This is discussed with residents and relatives on admission to the home. Two complaints have been received by the home one due to surgery not issuing a prescription and one relating to chiropody, both have been dealt with by the staff at the home. The registered person ensures that service users are protected from abuse via detailed policies and procedures to ensure that staff, were aware of practices to be followed in the home. Staff training, observations of staff and residents, and discussions with residents. Any allegations or incidents of abuse would be promptly followed up and recorded. Policies and procedures are in place for dealing with resident’s finances. Where resident’s personal allowance is managed by the home money and valuables are securely stored. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 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 standard(s) 19,20,24,25,26. The standard of the environment within this home is good providing service users with an attractive and homely place to live where they can relax and enjoy their chosen life style. EVIDENCE: Located alongside the busy A34, the home was purpose built to offer accommodation to older people with a physical disability or mental frailty. Residents on the ground floor had a clear access to the small garden area at the rear of the home. The environment within the home was warm comfortable and had a number of homely touches. Bathing and toilet facilities were located throughout the home; there was limited evidence of protective gloves and aprons in these areas this was discussed with management and areas where protective clothing is available are to be clearly identified to staff. Each resident had the option to use his or her en-suite, bedrooms were personalised to suit individual tastes. The home was well maintained and the staff should be congratulated for the high standard achieved. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 16 There were discussions with the providers to provide a rotary iron for the laundry a new steam iron has been provided. Staffs were aware of the COSHH regulations, which were available in the laundry. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30. At the time of inspection staff on duty at Lakeside were observed to be competent and satisfactory in number to meet the needs of individuals in their care. There are robust procedures in place for the recruitment of staff. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 18 EVIDENCE: As at the previous visit 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 x 5 days or split shifts as necessary to suit the home. Seven Care Assistants 8am – 2 pm Six Care Assistants 2 pm – 8 pm Five waking watchful night care assistants two of who would be a senior care cover night staffing. 180 Housekeeping hours’ domestics two start at 7am, 3 start at 8 am all finish at 2 pm. Kitchen staffs prepare tea and care staff serves. Handy person 9-4.30 pm. The home employs a Catering Manager/Chef to oversee catering in both homes on this site. Lakeside has its own full sized kitchen that was registered at the same time as the home but has never been operational. 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/Pova checks are carried out before confirmation of appointments. 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. The registered person has in place a training programme all staff received induction and foundation training working through a three months induction booklet. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,38. The manager is supported well by the proprietors in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities, thus ensuring the Health, Safety and Welfare of residents is observed. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 20 EVIDENCE: Policies and procedures are in place for quality assurance, the home also has in place an annual development plan this is based on planning and reviews for residents. Resident’s surveys are carried out and feedback is received from individuals via surveys, discussions and care plan reviews. Verbal feedback is sought from relatives and friends of residents. Individuals were aware that an Inspection was taking place today. All policies and procedures have been reviewed and updated to ensure compliance with National Minimum Standards. The registered manager ensures that residents who wish to are able to handle their own finances. A secure facility is provided in the resident’s bedroom for safe storage of valuables and monies and there is also a main safe. Remaining residents 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 resident. The registered manager ensures as far as is reasonably practicable the health, safety and welfare of residents and staff. Safe working practices are carried out staff are trained and aware of hazardous substances. Regular servicing of equipment and systems is carried out. Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION 3 3 x x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 22 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 15 Regulation 16 (2) (g) (i) Requirement Attention be given to the cleaning of the deep fat fryer, large chest freezer and small fridge and replacement of seal on fridge. A fly screen be fitted to the kitchen door. Cloths used in the kitchen and containers be maintained in a hygienic condition. Food being transported around the home to individual bedrooms must be covered. Timescale for action 2 Weeks from the date the report goes out and remains ongoing. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations Risk assessments clearly identify action to be taken Lakeside Residential Home E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Stafford - 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 E51-E09 S4968 Lakeside S240986 310805 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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