Inspection on 22/03/07 for Flanshaw Lodge

This inspection was carried out on 22nd March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Flanshaw Lodge 28/09/06

Flanshaw Lodge 03/02/06

Flanshaw Lodge 21/07/05

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 Key Unannounced Inspection 22nd March 2007 10:00 X10015.doc Version 1.40 Page 1 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 Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 2 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 DS0000034936.V330742.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Flanshaw Lodge Address 102 Flanshaw Lane Wakefield WF2 9JE Telephone number Fax number Email address Provider Web 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 www.wakefield.gov.uk Wakefield MDC Mrs Tina Payne Care Home 26 Category(ies) of Dementia - over 65 years of age (26) registration, with number of places Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide accommodation and care for 8 named service users in OP category. 28th September 2006 Date of last inspection Brief Description of the Service: Flanshaw Lodge is situated in a residential area of Wakefield. This Local Authority run home has recently been registered to provide residential care for 26 people who are suffering from dementia, including respite and interim care. A small number of residents who do not suffer from dementia have chosen to remain at the home since the change of registration. Set back in its own grounds, the home provides car parking to the rear and a large newly developed, enclosed garden area to the side and front of the home. 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 and dining areas, available on both floors. 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 access to transport for organised outings and provides activities within the home on a regular basis. A visiting hairdresser attends on a weekly basis. All bedrooms are personalised and residents 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. The manager informed the Commission that the charges for living at the home, as of March 2007, are based on an individuals’ weekly income minus their personal allowance and will vary from person to person but with a current limit of £494.51 per week. Extra charges are made for hairdressing, newspapers etc. Information about the home is available within the Statement of Purpose and the Service User Guide, both of which have been revised to reflect the changes in the categories of care and are given to all residents and prospective residents. Details of the Commission for Social Care Inspection are included within the Service User Guide, as is the summary of the last inspection report. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home made as part of a full inspection which took place on 22 March 2007. The visit lasted from 9.30 am to 2.30 pm. Time was spent in communal areas speaking to residents and staff and in the office speaking with the manager and checking documentation. As part of this inspection the views of residents, relatives, healthcare professionals, including General Practitioners and involved district nurses, were sought by way of surveys. The outcome of the survey was as follows: Of the 10 residents’ surveys sent out, 6 were returned, all of which were favourable but did not contain any specific comments. Some of these surveys had been completed with the assistance of staff due to the resident suffering from dementia. Of the 10 relatives’ surveys sent, 6 were returned, again these were favourable including comments such as “In a relatively short period of time, there has been an improvement in my mother beyond belief” and “Flanshaw Lodge always do everything well, I have no worries whatsoever about the care my Mum gets from the staff”. Of the 6 health care professional surveys sent, 4 were returned although one had not been completed. Comments were favourable with one district nurse commenting “All the staff seem genuinely caring and attentive to their clients”. In writing this report, information and evidence was not only obtained by way of visiting the home but also from notifications and information sent to CSCI and from previous CSCI inspection reports. In gathering evidence, CSCI undertook case tracking, reviewed documentation, sought feedback from residents and their families, staff and the home’s manager, and undertook relevant observations and discussions appropriate to needs of the residents, taking into account their needs and communication needs. The inspector would like to thank residents, their relatives and staff for their time and assistance during this inspection. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is Good. No new resident is accepted without an assessment being completed to ensure that their needs can be met at the home Intermediate care is not available at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that, wherever possible, a senior member of staff from the home will meet prospective residents and complete an assessment of their needs before offering a place at the home. In the case of an emergency where a meeting is not possible, a copy of the Local Authority’s Easy Care assessment document is always obtained prior to a place being offered. Evidence of pre admission assessments taking place was seen within residents’ files and were seen to provide a basis to the initial care plan. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is Good. Residents’ personal health and care needs are met through a holistic approach including care planning, involvement of health care professionals and safe systems for medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit to the home four care plans were examined, three of these were for permanent residents and one was for a resident receiving respite care. All of the care plans gave clear information about the individuals’ needs and how staff could meet these needs, taking into account residents’ strengths and abilities. The inclusion of details such as “likes plenty of bubbles” when outlining a person’s needs in relation to bathing and “enjoys a cup of tea before going to bed” demonstrate that staff at the home appreciate the importance of individual preferences. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 11 All of the care plans seen included a history of the resident’s life and, positively, aspects of this had been included in the care plan. Care planning has been further developed in view of the home’s recent change of registration category and good plans are now in place in relating to behaviours and communication problems that may be a feature of dementia but this is well balanced with promotion of independence. Residents’ dignity needs are considered within their care plans and observations made during the visit were that residents are afforded privacy and respect by staff at the home. All of the residents spoken with, who were able to comment, spoke fondly of the staff and observations made during the day were of a caring, respectful and easy relationship between residents and staff. The care plan for the person receiving respite care was being added to on an almost daily basis as staff get to know the person concerned. This high standard of careful care planning ensures that residents’ health needs are outlined and records show that the home works very well within a multi disciplinary team, including mental health services, district nursing and GP services to ensure that these needs are met. Documentation shows that care plans are reviewed on a three monthly basis or as required. Procedures for the storage and administration of medication were checked and found to be well managed. Regular audits are completed to ensure that systems are in place to ensure residents’ safety. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is Good. Residents are supported and enabled to make choices about their lives within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that, although the home does not have a dedicated activities organiser, staff are available to spend time every day taking part in activities with residents. In addition to this, activities personnel from the Local Authority visit the home twice monthly to engage residents in organised activity sessions. To further enhance social activity and contact, the manager said that residents from the home and service users from the adjoining day centre have begun to get together for some activities within Flanshaw Lodge. One of the residents spoken with said that they had been engaging in activities with a member of staff during the morning but was looking forward to a relaxing afternoon. The manager said that residents were enjoying preparing for Easter by getting involved in some craftwork. Several residents spoken with Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 13 were looking forward to an afternoon of entertainment followed by a fish and chip shop tea the day after the inspection. Relatives and friends of residents who replied to the Commission within the surveys all said that staff at the home supported their relative to maintain contact with them. Care plans indicated that residents were supported to have choices and control within their lifestyles. One relative said in a survey “The care staff treat people with respect, tolerance, understanding and accepting that the residents have rights”. The midday meal on the day of the visit was a choice of braised steak or corned beef with a selection of vegetables followed by a choice of desserts. The meal was taken mainly in one of the two dining rooms but some residents chose to eat in the lounge. Condiments and gravy boats were available on tables and staff were seen to support residents to eat where this was required. Positively, staff were seen to use a fork when assisting people to eat their main course rather than using a spoon throughout the meal. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is Good. Residents and their relatives are confident that any concerns they have will be taken seriously and that good procedures for safeguarding people are in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure is made available both within the Service User Guide and on notice boards in the home. All residents and their representatives who returned surveys to the Commission stated that they knew how to make a complaint. Complaints and, positively, compliments books are both kept in the entrance hall for people to see. Another complaints book is kept within the office for confidential or serious complaints. Very positive comments about the care at the home had been made in the compliments book. No complaints or concerns have been received by the home, or by the Commission in relation to the home, since the last inspection. Training records show that all staff have undertaken training in relation to safeguarding vulnerable adults through the Local Authority’s own training section. A member of staff was able to confirm what actions they would take should a safeguarding issue arise. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26.Quality in this outcome area is Good. The home provides a safe, pleasant, homely and comfortable environment for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Maintenance and redecoration is organised through the Local Authority’s estates department and ensures a good standard of safety within the home. The home appeared clean and tidy throughout. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 16 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is Good. Residents are supported by a team of well trained staff, available in sufficient numbers to meet residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that she is quite happy with staffing levels for the home at the moment. Additional staff hours have been put in place as the occupancy levels have increased. None of the surveys received by the Commission indicated any problems with the availability of staff and residents spoken with during the visit said that staff were there when they needed them. A staff training matrix was seen and indicated that all staff in the home are receiving training relevant to their position and, in particular, are still receiving training in caring for people with dementia. The manager said that all staff have personal development plans which are discussed during supervision when any training needs are identified. Only four of the 15 care staff in the home do not yet hold the NVQ level 2 certificate in care but they are registered to start studying for the award shortly. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 17 Electronic files for four members of staff were viewed and contained all of the information required to protect residents. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 18 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is Good. The home is well managed by a person who ensures that systems are maintained to protect and support residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s manager has many years’ experience of running care homes and has completed her Registered Managers award. A programme of quality monitoring is ongoing which includes gaining the views of residents, their representatives and professional visitors to the home. Regulation 26 quality monitoring visits are made to the home on a monthly Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 19 basis by a representative of Wakefield Metropolitan District Council and reports are forwarded to the Commission. The home holds small amounts of money for residents who choose to use this service in the home’s safe. Documentation relating to this and amounts held were checked and found to be accurate. Staff at the home are supported by a maintenance man and WMDC’s building services department to ensure that health and safety within the building is maintained. Information sent to the Commission by the home’s manager prior to the visit confirmed that appropriate health and safety checks are maintained. Records relating to fire safety checks and fire drills were seen and indicated that systems are being followed. Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 20 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Flanshaw Lodge DS0000034936.V330742.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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