Inspection on 03/02/06 for Flanshaw Lodge

This inspection was carried out on 3rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 Unannounced Inspection 3rd February 2006 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.V253830.R01.S.doc Version 5.1 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.V253830.R01.S.doc Version 5.1 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 Wakefield MDC Mrs Tina Payne Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Respite care for 2 service users The work required to meet the recommendations of the latest Fire Officer’s report is completed by 31 March 2004 or within an earlier timescale if this is stipulated by the Fire Service The care staffing hours are calculated by the provider using the Residential Forum staffing model and the number of full time equivalent staff appointed is in accordance with this calculation or otherwise as agreed in writing with the Commission. 27th July 2005 3. Date of last inspection 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 currently undertaking a refurbishment programme at the home and have applied to the Commission to vary the registration category of the home in order to to provide a unit specialising in caring for older people suffering from dementia. Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection made on 3rd February 2006. 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: Daily recordings in care plan files could be improved. Health and safety issues highlighted in the report concerning medication and fire safety need to be addressed as a matter of urgency. Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 6 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 DS0000034936.V253830.R01.S.doc Version 5.1 Page 7 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.V253830.R01.S.doc Version 5.1 Page 8 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 the following standard(s): 3 and 6. Although no admissions are currently being accepted, previous inspection visits have established that no resident moves into the home without having their needs assessed. Intermediate care is not delivered at the home. EVIDENCE: The home manager said that no admissions are being accepted to Flanshaw Lodge until the refurbishment programme and change of category of care has been completed. Intermediate care is not delivered at the home. Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7, 9 and 10. Individual care plans are in place, which set residents needs in respect of their health, personal and social care needs. A safe system for storage of medication is not maintained, which is a potential risk to residents. Residents are treated with respect and their right to privacy is maintained. EVIDENCE: Care plans seen gave details of individual’s needs and what actions need to be taken by staff to meet these needs. Where necessary care plans were linked to risk assessments and recordings made in the daily notes. Some of the daily notes needed to include better detail of specific events as some of the language and wordings used were misleading and in some cases judgemental. Systems for the receipt, storage and administration of medication were checked. Amounts of medication received into the home are not always being recorded which makes checking of stock balances impossible. There was evidence to suggest that correct procedures for ordering of medications were not always being followed as one box of medication, which is administered on a daily basis, had a supply date from the chemist of November 2005. MAR (Medication Administration Record) sheets, had not always been completed to Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 10 indicate whether or not the medication had been administered and in what strength. All of the residents spoken with, and who were able to express an opinion, said that they were very happy with the care they received at the home. One person said that that staff “couldn’t do enough to help” and another said that staff were “ always very kind”. Residents referred to staff by their names and spoke of their confidence in them. Staff were observed to knock on residents bedroom doors, and wait for an answer, before entering. Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 15. Residents enjoy a varied and balanced diet with plenty of choice available to them. EVIDENCE: All of the residents spoken with said that they were very happy with the food supplied at the home and said that there was plenty of choice available to them. Meals are taken in the dining room or, if preferred by the resident, can be taken in their rooms or in the lounge areas. Cold drinks are available at all times in all of the lounges. Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 16 and 18. Systems are in place to give residents and their relatives confidence that their complaints will be listened to and acted upon appropriately. Training and procedures are in place to ensure that residents are protected from abuse. EVIDENCE: A robust complaints procedure is in operation at the home. Evidence was seen that all complaints and concerns, however minor, are dealt with through this process. Staff have received training in abuse awareness and protection of vulnerable adults. Positively, the manager said that she had made a referral to adult protection, as she was unsure about a recent issue, which she felt may have the potential to affect residents safety. Documentation relating to this was seen and it was clear that all appropriate actions had been taken by the manager and staff in order to protect the residents concerned. During the visit a social worker arrived at the home to speak with one of the residents concerned. Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19 and 26. The home continues to provide a very pleasant environment for residents to live in. EVIDENCE: Despite a refurbishment programme going on at the home, high standards of maintenance and cleanliness are being maintained at the home. All of the staff involved should be congratulated on their efforts to ensure that disruption to residents during this process is kept to an absolute minimum. Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30. Recruitment policies and procedures are in place to protect residents. Staff training is ongoing although the level of training in dementia care undertaken, particularly by the home’s manager may not be sufficient to meet the needs of prospective residents. EVIDENCE: A selection of electronically held staff records were seen and were found to contain all the documentation required by regulation to protect residents. Training is ongoing at the home with staff being prepared for the forthcoming change in registration category. The home’s manager said that she completed some training in dementia care although this has consisted mainly of only half day courses, but is hoping to do the diploma in dementia care course as she feels that she has training needs in this area and is confident that this course will meet these needs. Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38. The health and safety of residents and staff may be put at risk by inadequate testing of fire alarms. EVIDENCE: Records relating to health and safety within the home were seen. Although the manager said that tests had been carried out, no record of fire alarm testing had been made since the beginning of November 2005. Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 16 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 2 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 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 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 1 Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 reciept and recording of medications received at and administered at the care home. Two previous timescales given for this requirement have not been met. The registered person must make arrangements for testing fire detection systems on a wekly basis. Results of this test must be recorded. Timescale for action 20/02/06 2. OP38 23(4) 20/02/06 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. 2. Refer to Standard OP7 OP30 Good Practice Recommendations Daily records should give specific and clear detail of events and staff should take care not to use judgemental language. The home’s manager should commence training relevant to managing a dedicated dementia care home. DS0000034936.V253830.R01.S.doc Version 5.1 Page 18 Flanshaw Lodge Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road 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. Extracts may not be used or reproduced without the express permission of CSCI Flanshaw Lodge DS0000034936.V253830.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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