Inspection on 05/05/04 for Waters Edge Care Home

Care Home For Older PeopleLakeside Residential HomeUnannounced Inspection5 May 2004 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 Alpha Healthcare Ltd, Croft House, Moons Moat Drive Moons Moat Drive, North Moons Moat, Redditch Worcs, B98 9HN 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 6 June 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 30 December 2002 YES NO 12/12/03 If Yes refer to Part CLakeside Residential HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 35 May 2004 09:00 am Mrs Kathryn Marks Mrs Wendy GraingerID Code075892Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at 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 Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & 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 Conditions (if applicable) Providers Response Providers Comments Action Plan Providers Agreement Kathryn Marks Stuart Rudd 23 July 2004 Signature Signature SignatureLead Inspector Second Inspector Locality Manager Date Public reportsKathryn Marks Stuart RuddIt should be noted that all CSCI inspection reports are public documents.Lakeside Residential HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), 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 CSCI 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 CSCI 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 63 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.) This inspection took place over one day on Wednesday 5 May 2004. 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. 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) 3 of the 3 standards assessed were met. Standard 1 the service users guide must include all areas identified in Standard 1.2 of the National Minimum Standards. This was a requirement of the previous report and remains a requirement. Standards 3, 4, 5 were met. Standard 6 is not applicable to the home. All service users have statements of their terms and conditions of residence at the home. All have an assessment of their needs carried out prior to admission. Health and Personal Care (Standards 7-11) 3 of the 3 standards assessed were met. Standards 7, 8, 9, were met, Standards 10 & 11 were not assessed on this occasion but met standards at previous inspection. Arrangements were in place for meeting the health and personal care needs of individuals and all have care plans that are detailed and highlight care needs. If appropriate individuals are able to self medicate and are provided with a secure facility for storage of medication. Service users confirmed to the inspector that privacy and dignity are promoted at the home. Daily Life and Social Activities (Standards 12-15) 1 of the 1 standard assessed was met Standards 12, 13, 14, were not assessed on this occasion but were assessed at previous inspection visit and met standards. Standard 15 was met. There were positive comments from the majority of service users about the food they said they were provided with. Visitors were observed making coffee for themselves in the kitchenette.Lakeside Residential HomePage 6 Complaints and Protection (16-18) 3 of the 3 standards assessed were met Standards 16, 17, 18, were all met. The home has received no complaints since the last inspection. There is a complaints procedure in place that service users spoken to said they were aware of. Individuals said if they were unhappy about something they would talk to a member of staff. Environment (Standards 19-26) 8 of the 8 standards assessed were met The management and staff at Lakeside maintained high standards of hygiene and should be congratulated there was no evidence of malodour. 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. 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. Staff were made aware of the importance of cross infection via training and being provided with the appropriate protective clothing. Staffing (Standards 27-30) 3 of the 3 standards assessed were met Standards 27, 29, and 30 were met. Standard 28 was not assessed on this occasion but met standard at previous visit. 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 month induction and a staff-training programme to ensure staff are trained to do their job. Management and Administration (Standards 31-38) 4 of the 4 Standards assessed were met Standards 31, 32, 35and 38, were met. Standards 33, 34, 36 and 37 were not assessed on this occasion but met standards at previous inspection visit. 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. Areas of administration examined were detailed and up to date.Lakeside Residential HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY 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. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 5.1 OP1 The service users guide must include all areas identified in Standard 1.2 of The National Minimum Standards as discussed at the time of inspection with the Care Manager 1 Month from the date of the report going out.Action is being taken by the Commission for Social Care Inspection 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)STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Lakeside Residential Home Page 8 Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements 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. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS 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). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 3 4 OP30 OP9 OP26 OP38 Health and Safety training to be arranged for domestic staff. To continue using the official controlled record for prescribed medication in conjunction with the daily audit record. To provide a thermometer in each bathroom for use each time a service user is bathed. To consider the suggestion of a more logical method for the weekly testing of the fire system as discussed.* 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 9 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 NO YES YES YES YES NO YES NO YES YES NO YES NO YES YES YES NO YES 23 7 X NO YES YES YES 41 0 5/05/04 0900 8Lakeside Residential HomePage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people 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 11 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 (£) 292.25 To (£) 420.00Any charges for extrasYESIf 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, services/facilities provided at the home. The service users guide should be reviewed and updated to include all information identified in Standard 1.2 of the National Minimum Standards. This was a requirement of the previous report and will be a requirement of this report. All service users and their relatives have been given information on how to contact the Commission for Social Care Inspection.Lakeside Residential HomePage 12 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? As at the previous inspection 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. 0 Key findings/Evidence Standard met? This standard has not been assessed on this occasion but was assessed on the previous inspection visit and met the standard.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 identify clearly what staff need to be doing to meet the identified needs. Three service users were case tracked, care plans and any other written information relating to them was observed and all were spoken to. All specialist services offered are based on good practice, staff training, liaising with outside organisations and accessing professional advice. 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.Lakeside Residential HomePage 13 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 14 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 an assessment of individual needs being completed, the service users plan of care is produced. This involves the service user and carer 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. Detailed reviews of care plans take place monthly. There were no service users who were subject to requirements of the Mental Health Act 1983.Lakeside Residential HomePage 15 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. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 19 33 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. The homes current General Practitioners have given the home notice from the 31 July 2004. Cannock Primary Care Team are having a meeting to discuss the allocation of new General Practitioners. All service users are encouraged to be independent with oral hygiene with help being available as required. Where individuals are felt to be at risk of developing pressure sores an assessment is carried out by the District Nurse and appropriate action is taken. There are currently three service users with pressure sores and these are dealt with by the district nurse, nursing notes were seen. The district nurse was spoken to by Inspectors and offered positive comments about the home. 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. 3 Key findings/Evidence Standard Met? A minimum number of the service users choose to self-administer their inhalers. The home maintained policies and procedures in respect of the administration and storage of medication. These were combined with the training programme staff had undertaken. The storage of the prescribed medication was satisfactory. The senior person on duty and responsible for the medication during the inspection demonstrated her knowledge of the service users and prescribed medication. It was recommended and discussed with the care manager that the staff responsible for the administration of any controlled drug use the official controlled drugs record in conjunction with the daily audit put into place following the last inspection.Lakeside Residential HomePage 16 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. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but was assessed at the previous inspection and met standard.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. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but was assessed at the previous inspection and met standard.Lakeside Residential HomePage 17 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. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but was assessed at the previous inspection and met standard.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. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but was assessed at the previous inspection and met standard.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. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but was assessed at the previous inspection and met standard.Lakeside Residential HomePage 18 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. 3 Key findings/Evidence Standard met? The menus seen today were discussed with the chef. They were a four- week sample of the meals prepared. This sample would be made available to any person making an enquiry for a placement. The meal of the day was displayed on the notice boards and although did not reflect the meal identified on the written menu; service users confirmed that they had been served Lamb the previous day. The service users told the inspector that they were asked the previous day for their choice. Some service users said they could not always remember what they had chosen. The meal of the day was Steak & Kidney pie with an accompaniment of potatoes and vegetables, followed by Lemon Meringue. On offer at teatime were Jacket potatoes with Chilli or a selection of sandwiches.Lakeside Residential HomePage 19 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 that 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 No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The home displayed the policy for making a complaint within the front entrance hall. The Commission for Social Care Inspection had received no complaints since the last inspection. The management told the inspectors that no formal complaints had been made to the home. No complaints have been made to the Commission for Social Care Inspection.Lakeside Residential HomePage 20 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? As at the previous inspection 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 had been registered on the electoral role.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 X3 Key findings/Evidence Standard met? The majority of the staff had NVQ level II. Training on elder abuse has now been covered by 60 of staff to ensure that service users were protected against abuse. Its proposed that this training will be ongoing with regular updates taking place. 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 21 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 stated purpose. The home had a level patio area surrounded by lawns, there was a routine decorating and refurbishment programme in place. The home did not have CCTV cameras.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? As at the previous inspection 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 22 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 favourite possessions of the individuals choice. 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; a bathroom on the first floor was having new flooring fitted.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. Some service users had been admitted to the home with their personal equipment i.e. walking frames and walking sticks. Equipment had been purchased to benefit the service users since the home opened in 2000. The inspectors discussed the fund raising efforts by the staff and donations from which, will be used to purchase a Stand-aid. Equipment needed to benefit the service users and as part of the homes equipment should be assessed by a suitably qualified person and purchased by the company. 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 23 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 55 55 4 4 55 X13 X 4 X3 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. Bedrooms were for single and shared occupancy. Each of the service users were provided with an en/suite facility.Lakeside Residential HomePage 24 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 was comfortably furnished; the majority of the service users on the ground floor chose to remain in their bedrooms. The standards throughout the home were exceptional and the staff should be congratulated. The inspector identified in the majority of the bedrooms many favourite possessions, which had been brought into the home by service users to personalise their rooms. 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 heating and ventilation throughout the home was satisfactory, windows were fitted with restraints, in line with Health & Safety requirements. Radiators were the low surface type and the pipe work was covered. Water temperatures were tested weekly and a record was maintained, this record was evidenced during the inspection. 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? During a tour of the home it was identified that no malodours were present. The toilets and bathrooms were satisfactory in their hygiene, clinical waste was contained in the appropriate container. It was recommended to the care manager that more thermometers should be purchased for the bathrooms. The testing of water on the wrist as explained by one of the staff would not be acceptable. The laundry was located off one of the corridors on the ground floor, this area worked well and the staff had been made aware of COSHH regulations via training. The staff and service users would benefit from having a rotary iron; ensuring that linen was flat which, would be part of the health care of service users preventing the possibility of a pressure area.Lakeside Residential HomePage 25 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 0 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 No. of care staff No. of ancillary staff Key findings/Evidence 31 21 0 No. staff hours allocated No. staff hours allocated No. of staff hours provided 0 0 1078 0 0 00 41 16 Standard met? 3Lakeside Residential HomePage 26 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 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. Six Domestics all start at 8am, three finish at 12 midday, three finish at 2pm. Deployment of domestics has been reviewed to give cover at teatime to avoid care staff coming off care duties and this reorganisation is still in hand. Handy person 9-2. The current arrangements for catering at Lakeside remain the same that cooking staff are based at Hardwick Court and meals are brought over to Lakeside. This arrangement should be kept under review as this was agreed on a trial basis when the home first opened. Feedback from service users on food varies depending who you talk to. The home is now employing 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 in July 2001.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 the 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 X X 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but met standard at previous inspection.Lakeside Residential HomePage 27 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? As at the previous inspection 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 has a training profile and receive three paid days training a year. The housekeeper is to arrange Health and Safety training for domestic staff.Lakeside Residential HomePage 28 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, and has now achieved the Registered Managers Award. 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? As at the previous inspection 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 29 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. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but was assessed at previous visit and met standard.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but was assessed at previous visit and met standard.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. A secure facility is provided in the service users bedroom for safe storage of valuables and monies and there is also a main safe. 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.Lakeside Residential HomePage 30 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. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but was assessed at previous visit and met standard.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. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion but was assessed at previous visit and met standard.Lakeside Residential HomePage 31 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. 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 temperature of the water was tested and recorded on a weekly basis; the maintenance person was able to adjust the thermostats if necessary. Each of the floors had a maintenance report record book. Fire tests of the system were completed each Fridays at 11.30am. The inspector was concerned that there was a fault on the system which had occurred on Monday and the firm although had been contacted were not due until possibly Friday. A more logical method of testing the system was discussed with the maintenance person and care manager. Each of the zones will be numbered and tested in rotation; this will ensure that no point was missed. The most recent fire drill was 18 3 2004. The care manager will introduce a fire drill column to the matrix ensuring that each member of the staff was involved in a fire drill over the 12 month period. The inspector evidenced records for the testing of the Hoists, Lift, and Gas all of which were current. 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 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLakeside Residential HomePage 33 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 5 May 2004 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 34 Action taken by the CSCI 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 29 July 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 35 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 36 - 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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