Inspection on 21/07/05 for Flanshaw Lodge

This inspection was carried out on 21st 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Flanshaw Lodge 22/03/07

Flanshaw Lodge 28/09/06

Flanshaw Lodge 03/02/06

Flanshaw Lodge 25/01/05

Flanshaw Lodge 22/07/04

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

CARE HOMES FOR OLDER PEOPLE Flanshaw Lodge 102 Flanshaw Lane Wakefield WF2 9JE Lead Inspector Gillian Walsh Unannounced 21 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. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Flanshaw Lodge Address 102 Flanshaw Lane Wakefield WF2 9JE 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) 01924 302250 Wakefield MDC Mrs Tina Payne Care Home 31 Category(ies) of over 65 - 31 places registration, with number of places Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 25 January 2005 Brief Description of the Service: Flanshaw Lodge is situated in a residential area of Wakefield. This Local Authority run home provides residential care for 31 people, including respite and interim care. Set back in its own grounds the home provides car parking to the front and a large newly developed garden area to the rear. The home has a number of lounges one of which is provided for service users who smoke. There is a large dining room and a number of smaller quiet lounges, one of which is on the first floor. All service users are provided with single bedrooms situated on the ground or first floor, and there is a shaft lift to the first floor if required. The home has a programme of activities and access to transport for organised outings. A visiting hairdresser is employed by the home. All bedrooms are personalised and service users are encouraged to bring their own furniture. Residents’ spiritual needs are met either by visiting clergy or by visits to residents’ chosen places of worship. Wakefield Metropolitan District council are planning to change the registration of Flanshaw Lodge, following a refurbishment programme, to provide a unit specialising in caring for older people suffering from dementia. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection made on 21 July 2005. Time was spent talking to residents and staff, taking a tour of the building, which included looking at some bedrooms, checking systems for medication and looking at documentation including care plans. The inspector would like to thank residents and staff at the home for their time and assistance during the visit. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 6 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 Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 7 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) 3 All prospective residents have their needs assessed before moving into the home to ensure that staff are aware of, and can meet, their assessed needs. EVIDENCE: No permanent admissions are being accepted to Flanshaw Lodge until the proposed refurbishment and change of category of care has been completed. Interim care admissions are being accepted and the assistant manager said all relevant assessment information, completed by appropriate professionals, is obtained prior to the resident being accepted into the home. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 8 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 and 9. Individual care plans are in place and residents are happy that their health needs are met appropriately. A safe system for storage of medication is not in place which is a potential risk to residents. EVIDENCE: All of the care plan files seen included a care plan detailing resident’s strengths and abilities within the activities of daily living, and detail of any interventions necessary to support these abilities. Daily records in some files gave good detail of how residents had chosen to spend their time and how their physical and psychological needs were being met but others were very brief. Some of the files evidenced that residents are involved in their care planning but this was not included in all of the files seen. Other information in files included various assessments and their outcomes, detail of specific likes and dislikes with regard to how service users like to spend their time and any preferences with regard to food and drinks. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 9 Evidence was available within the files that residents health needs are met by visits from GP’s, district nurses, chiropodists, dentists etc or by visits to local clinics or hospitals. Several residents said that they were very happy with how staff deal with their health needs and that they can access healthcare whenever necessary. Systems for the receipt, storage and administration of medication were checked. Although stored in a locked room, the medication trolley was found to be unlocked. Amounts of medication received into the home are recorded although the stock balances of two of the medications checked were incorrect. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 10 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 and 14 Residents feel that their expectations and preferences are considered and satisfied by staff at the home. Encouragement is given to residents to exercise choice and control over their lives and support is given to enable residents to maintain contact with family and friends. EVIDENCE: The assistant manager told the inspector that activities are held on a daily basis although these are not timetabled. Additionally activities staff from the local authority visit the home approximately 3 times each month to work with residents. Several residents said that they enjoyed joining in with activities of their choice when they felt like it but did enjoy peace and quiet and just sitting chatting with each other or their visitors. Visitors are welcomed to the home and residents can choose to see their visitors either in their room or in the communal areas. Evidence is available within care plans that residents are encouraged to exercise choice over their lives and this was confirmed in conversation. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 11 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) 17 Residents legal rights are protected whilst living at the home. EVIDENCE: Residents confirmed that they are confident that their legal rights are maintained and protected whilst living at the home. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 12 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 and 26 Resident’s safety could be put at risk by the practice of wedging open the door to the smoking area. The home provides a very pleasant environment for residents to live in. EVIDENCE: The home is shortly to undergo refurbishment as part of the change in category of care and therefore any redecoration will take place as part of this process. During a tour of the building it was noticed that generally the building is maintained in a safe condition although it was of concern that the door to the residents smoking lounge was held open with a wedge. Standards of cleanliness are maintained to a very high level and the home provides a very comfortable and homely environment. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 13 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 and 30. Residents are supported by a well-trained and caring staff group, available in sufficient numbers to meet the needs of those in their care. Systems were not in place to enable the inspector to assess recruitment practices. EVIDENCE: Residents said that staff are always available to help them as required and that they are not kept waiting for assistance. Only 5 of the current staff group at the home have not yet achieved NVQ level 2 although arrangements are in place for these staff to receive the training. NVQ training is organised for all staff at the home including catering and ancillary staff. The assistant manager was unable to access the electronically held staff records and despite calls to the relevant department within the council, the inspector was unable to arrange computer access to these records. The inspector spoke with a number of staff who were all looking forward to the proposed changes at the home and were very satisfied with the training they were receiving in order to prepare them for caring for people suffering from dementia. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 14 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 and 38. Residents feel that the home is run in their best interests. The wedging open of the smoking room door presents a risk to residents and staff. EVIDENCE: Residents said that their opinions are sought in relation to the running of the home. A lot of consultation has taken place with residents regarding the proposed change of care category at the home. Records relating to health and safety including PAT testing, electrical records, emergency lighting and fire training were seen to be up to date. The wedging open of the fire door to the smoking lounge (see standard 19) is a potential risk to the health and safety of residents and staff. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 15 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 1 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 x x x 3 x x x x 1 Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 16 YES 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 OP9 Regulation 13(2) Requirement The registered person must make arrangements for the safe recording and storage of medications received into the care home. This requirement was made in the previous report. The registered person must seek the advice of the fire officer in relation to making adequate arrangements for containing fires. The practice of wedging open the door to the residents smoking room must stop. Systems must be put in place to ensure that staff files are at all times available for inspection by the Commission. Timescale for action From 21.7.05 2. OP19 OP38 23(4)(c) (i) From 21.7.05 3. OP29 17(3)(b) Schedule 4 From 21.7.05 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 OP7 Good Practice Recommendations Evidence should be available within care plans that the resident, or where appropriate, their representative, has knowledge of and has agreed to the care plan. Daily records should include more detail of how service J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 17 Flanshaw Lodge users spend their time and any choices or decisions made within their daily lives. Flanshaw Lodge J51J01_s34936_Flanshaw Lodge_v236391_210705.doc Version 1.40 Page 18 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse. 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