Inspection on 27/07/05 for West Ridings Residential & Nursing Home

This inspection was carried out on 27th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

West Ridings Residential &... 31/10/08

West Ridings Residential &... 19/11/07

West Ridings Residential &... 24/01/07

West Ridings Residential &... 14/12/05

West Ridings Residential &... 16/02/05

West Ridings Residential &... 16/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE BUPA West Ridings West Ridings Lingwell Gate Lofthouse WF3 3JX Lead Inspector Tony Railton Unannounced 27 July 2005 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. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bupa West Riding Address Lingwell Gate Lofthouse Wakefield WF3 3JX 01924 826806 01924 825743 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) Care First Homes Ltd Deborah Campey Care Home 180 Category(ies) of PD(E) Physical dis - over 65 (75) registration, with number MD(E) Mental Disorder -over 65 (30) of places DE(E) Dementia - over 65 (45) OP Old age (150) BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The conditions of registration are displayed on the certificate in the home. Date of last inspection 16th February 2005 Brief Description of the Service: BUPA West Ridings although under one registration is comprised of six thirty bed units and provides a total of 180 places for older people, some of whom may suffer from dementia, mental health problems, have a physical disability and or require nursing care. There is a manager for each of the six units who are directly supervised by the Registered Manager. Ground floor accommodation is offered to all service users and some of the bedrooms have patio doors leading to the gardens. Other bedrooms face inner courtyards which have garden furniture for the use of service users during the summer months. Each unit has communal areas including lounges, dining rooms and quiet lounges. All bedrooms are personalised and there are assisted bathing facilities for those who require them. Prospective service users are invited into the home to test drive the services offered and visitors are welcome. There is a reception area provided with administrators and the registered managers office. This building also houses the central kitchen, laundry and training rooms.The home is situated in Lofthouse on the outskirts of Wakefield, is on a main bus route and is close to Outwood train station. There are some local shops nearby including a post office, public houses and health centre. West Ridings is only a few minutes journey from the centre of Wakefield and all services and amenities and is also close to the M1/M62 link roads. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by three CSCI Inspectors who collectively spent a total of 16 hours in the home. This was a very positive inspection in which a number of major improvements were noted. All of the Statutory Requirements from the last inspection have been met and most of the good practice recommendations. The inspection focussed on the outcomes for people living in the home and the inspectors took the opportunity to speak to most residents, some of their relatives, the unit managers, registered manager, nursing, care, domestic and kitchen staff, and the maintenance manager. The inspector would like to take the opportunity to thank the residents, registered manager and her staff for their hospitality and patience and cooperation throughout this very positive and enjoyable inspection. What the service does well: All residents’ bedrooms are personalised, clean, homely and comfortable. One resident said that she has everything she needed and was very happy with her room. Most residents have brought personal items of furniture with them for their bedrooms, including, chairs, tables, corner cabinets, pictures and photographs. A number of residents said that they are well cared for and liked the people looking after them. A number of relatives said that they are very happy with the care provided by the home. There was a good positive relationship observed between residents and their carers. The majority of residents spoken to said that the meals are good and that they have a choice. The catering manager said that everyone is offered a choice of menu on a daily basis. All, with one exception, the communal areas including lounges and dining rooms were observed to be clean homely and well maintained. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 6 Some bedrooms have patio doors leading to the gardens. One resident said that the view is “lovely” and it reminded her of her own garden. Residents appeared to be comfortable, happy and well cared for, they were observed to be appropriately dressed, were clean with their hair groomed, their nails manicured, and with clean spectacles. Activities are arranged and attended on a regular basis. There was evidence of a good positive relationship with other healthcare professionals who support and visit the home on a regular basis. What has improved since the last inspection? There have been a number of improvements since the last inspection. The home now has a new registered manager who is very experienced and competent. Unit managers, nursing and care staff benefit from having clear leadership including clarity of their roles and responsibilities. Staff spoken to said that they are much happier in their work and that they feel supported. Regular unit manager meetings are held and unit managers now receive regular line management supervision. Training for all staff has a high profile and courses include Leadership and Management (for unit heads), Equality and Diversity, Dementia and Adult abuse and Protection, and National Vocational Qualification training at levels 2, 3 & 4. The assessment and care planning systems have improved and are currently under review. Residents care plans are reviewed and updated on a regular basis. More permanent staff have been employed to ensure consistency in the way personal care is provided. The inspectors were pleased to note that there is no longer a heavy reliance on agency workers. There have been many improvements to the physical environment for the comfort and benefit of residents. The improvements include new carpets for some bedrooms, new chairs and commodes in others, some bedrooms have been completely refurbished. Some corridors have been re-decorated and new brighter lighting provided in others. New chairs have also been provided in most lounges. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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 BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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) 1,2,3,4, 5 & 6 Prospective residents, their relatives and others have the information they require to make an informed choice about the services provided by the home. Residents’ are also protected by having a written contract with the home. EVIDENCE: One bedroom was observed being prepared to receive a new resident who was visiting the home with his family to see the services and facilities offered. The senior carer said that everyone is usually given the opportunity to visit, socialise and meet the staff before they are admitted. The homes documentation shows that there is lots of information produced and given out to make sure that people know what services the home provides. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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 To ensure that residents personal and social care needs are met and to help care staff a consistent approach to writing care plans should be adopted. To ensure the safety and wellbeing of residents a review needs to be taken of the medicine administration systems. EVIDENCE: Examination of care plans on each unit show that there are inconsistencies in the quantity and quality of some care plans. The manager said that she is aware of this inconsistency and is, along with care plan training for staff, is currently introducing a new care planning system. The manager said that using the ‘14 Activities of Daily Living’ model may not always be appropriate. The manager also said, and the inspector agrees, that the care plans should be simpler and reflect what is important to the individual resident. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 11 The manager went on to say that changing the care plans will take time, organisation and training for staff. The inspector suggested that care plans identifying residents’ physical or medical needs are balanced with plans addressing their personal or social care needs. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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 Residents do have opportunities to make choices about their lives. A range of activities are also arranged and attended by those who wish to participate EVIDENCE: Through Discussion with residents, kitchen staff and senior carers and examination of some residents’ records it was found that residents do make decisions about what happens to them on a day to day basis. There were programmes of activities displayed on the notice boards and some residents were observed enjoying a game of Dominos and care staff were observed asking residents what they would like to do. The daily records, however, with the exception of the residents‘ menu choice checklists, do not effectively record residents’ choices and preferences or reflect the good work carried out on the units. The majority of residents spoken to said that the meals are very good and that they have a choice of menu. Three relatives spoken to said that they made to feel welcome and can visit the home at any time. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 13 One visitor said that she has been “coming to the home to see her friend for a number of years and has never had any problems or any reason to complain”. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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. There are systems in place to ensure that residents are safeguarded and protected from abuse neglect or self-harm. The complaints policy and procedure ensures that all complaints are investigated and taken seriously. EVIDENCE: Discussion with some residents, their relatives, the registered manager and care staff showed that residents and their relatives and staff know how to make a complaint. One resident said that if she had a complaint she “would tell the manager”. She went on to say that if there is anything to complain about she would also tell the inspector. Staff training records showed that Adult Abuse and Protection forms part of the induction training for new staff. The manager said that existing staff are also undertaking Adult Abuse Training. Discussion with the manager and examination of the regulation 37 reports show that two recent incidents in the home were appropriately dealt by the registered manager who followed the Wakefield Social Services and Health Multidisciplinary Adult Abuse and Protection Policy and Procedure. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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 & 26 Most residents’ benefit from living in a safe and well maintained home which is clean and comfortable, however, some residents on one of the units do not have any shared space which is comfortable and homely. EVIDENCE: Inspection of all six units showed that most residents enjoy living in a home which is well maintained, homely and comfortable. Through observation and discussion with the registered manager and domestic supervisor it was noted that the carpet in the lounges, dining room and corridors on the Calderdale Unit are heavily stained and need to be replaced. Some bedrooms were observed as requiring some minor remedial work. The senior carer said that these are in the repair book and the maintenance manager is aware. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 16 A number of improvements were noted throughout the units. These were more noticeable on the Nidderdale Unit which has been decorated since the last inspection. New chairs have been provided in the lounges and some bedroom and a number of bedrooms also have new carpets. One resident said that she “liked her bedroom very much”, another said he 2 had everything he needed, its home from home”. Two relatives said that they “are very happy with their relatives bedroom which is always clean, tidy and homely.” BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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) 27,28,29 & 30 Residents are protected by the homes recruitment policies and practices, and they are supported by an effective staff team. EVIDENCE: Major improvements were noted with regard to staffing levels and the amount of permanent staff employed in the home. The registered manager said that last year over 850 hours per week were taken up by agency workers. On the week before the inspection no agency staff were required and this week only 12 hours were needed. Both residents and staff benefit from this improvement. Residents receive consistency in the way they are cared for and staff said that they are much happier. One carer said that she “now feels part of a team”. Another said that “now she knows where she is, she can relax and enjoy her work”. It was noted that on the Calderdale unit it was particularly hectic at lunch time and there did not appear to be enough staff available to meet residents care needs. The registered manager said that she is currently reassessing the residents’ care needs on this unit and reviewing the deployment of staff. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 18 Staff training records showed that there are a few staff who needed update training in First Aid, Moving and Handling and Basic Food Hygiene. Staff training records show that over twenty staff have a National Vocational Qualification at levels 2, 3 and 4, however, the manager said that there is some way to go before 50 of carers are NVQ trained. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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) 31,32,33,34,35,36, 37 & 38. Residents and staff benefit from the ethos, leadership and management approach of the home and the health , safety and welfare of residents and staff are promoted and protected. EVIDENCE: Discussion with the unit managers and senior care staff shows that they are happy with the new manager and that they feel supported in their work. The new registered manager said that three permanent unit managers have been employed and the management systems within the home continue to improve. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 20 Staff supervision records show that there are some staff that need line management supervision. The inspector acknowledges that there are lots of new staff that will not have had line management supervision yet. The maintenance manager’s records show that there is appropriate fire alarm testing and training provided for staff. The water temperature records show that residents can bath safely without fear of scalding. Records show that the views of residents, their relatives and other stakeholders should be sought regarding the quality of care provided by the home. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 1 3 3 3 2 3 3 STAFFING Standard No Score 27 2 28 2 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 3 3 3 3 2 3 3 2 3 2 BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 22 N/A 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 20.7 Regulation 23 (2)(d) Requirement For the benefit and comfort of residents the carpets in the lounges, dining room and corridors on the Calderdale unit need to be replaced. Timescale for action The registered person needs to provide an action plan indicating when this will be completed 2. 9.4 13.2 For the safety of residents the registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines into the home. 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 7.2 & 7.6 Good Practice Recommendations A review should be undertaken of the care planning system as there should be a consistant approach to care planning, and care plans should be drawn up with the involvment of the service user, agreed and signed. Descriptive words should be used in the daily records to J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 23 2. 12.2 & BUPA West Ridings 14.1 3. 4. 5. 6. 7. 19.2 24.1 27.3 28.1 33.4 and 33.7 8. 38.2 reflect residents choices and preferences or any decisions they make about their day to day lives. The manager should provide a programme of routine maintenance and renewal of the fabric and decoration of the premises. The minor remedial work in the bedrooms identified should be carried out as soon as practicable. Th registered manager should undertake a review of the dependancy levels of residents and the deployment of staff on the Calderdale Unit 50 of care staff should be trained to NVQ Level 2 or above. The views of service users, their relatives and other stakeholders should be sought regarding the quality of care provided by the home, and the information collected through this process should be collated and a report published indicating the outcomes for residents. First Aid, Moving and Handling and Basic Food Hygiene training should be provided for those who require it. BUPA West Ridings J51J01_s6304_bupa west riding_v235603_270705.doc Version 1.40 Page 24 Commission for Social Care Inspection Park View House Woodvale Office Park Brighouse HD6 4AB 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. 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