Inspection on 09/11/05 for Lake View Manor

This inspection was carried out on 9th November 2005.

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

Lake View Manor 25/04/07

Lake View Manor 21/06/05

Lake View Manor 16/11/04

Lake View Manor 24/08/04

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Larchfield Manor

Hawkhills

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The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lake View Manor 29-30 Pearson Park Hull East Yorkshire HU5 2TD Lead Inspector Janet Lamb Announced Inspection 9th November 2005 09:00 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 Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 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. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lake View Manor Address 29-30 Pearson Park Hull East Yorkshire HU5 2TD 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) 01482 447476 Mr G Davies Mr G Abel Ms Elaine Garland Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: Lake View Manor is a large Victorian property made from two houses in Pearson Park in the west of the city of Hull. There is a bus route close by, a rear garden for residents to use and a small car park to the front. There are shops, pubs and health services close by. The home accommodates up to 26 residents who are elderly, in ten single and eight double rooms on three floors, accessed by a passenger lift. The house is well maintained and decorated and rooms are personalised. Staff provide personal care and support. Meals, entertainment and laundry are included in the care. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection of Lake View Manor took 4½ hours to complete and was the second of two inspections this year. The Inspector spent time talking to residents and some of their relatives, the Manager and one senior staff, and the cook. The house was not toured, but four rooms were viewed and all of the ground floor area was inspected. Some policies and procedures were seen, documents and records inspected. The Inspector observed practices and relationships and noted the activities offered and heard the visiting entertainer. 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. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 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 the following standard(s): 3 and 6. Residents are thoroughly assessed before moving into the home and are therefore given clear indication of whether or not their needs can be met. Residents have their needs well met by well-trained staff. Standard 6 is not applicable. EVIDENCE: There have been no changes to the systems or practices in the home since the last unannounced inspection on 21st June 05, and therefore evidence for the outcome to standard 3 remains the same. Two new residents and the Manager spoken to on the day of inspection confirmed the assessment and admission processes, and were aware of documents held in files. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10. Residents have good plans of care showing a comprehensive range of needs, which are well met by staff. Residents have their privacy and dignity maintained in a sensitive manner. Residents are protected by the home’s policies, procedures and practice for administering medication, or selfmedicating, and consider safety to be very important in this area. EVIDENCE: There have been no changes to the systems, policies or practices in the home since the last unannounced inspection, and therefore evidence to standards 7, 8 and 10 remains the same. There are comprehensive policies and procedures for handling medication and there is evidence of a good medication ‘trail’. The local pharmacist provides a three monthly medication administration training session to staff as well as an audit on how medicines are stored, handled, disposed of safely etc. The next instruction will be 17th November 05. The Manager also assesses staff for competence before allowing them to administer medication. Records for administering medicines are up-to-date and accurately completed. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 Page 9 There are no residents self-medicating at the moment and those spoken to had differing views on the subject, but no one objected to the home being in control of medication. One felt it was imperative residents did not hold their own medicines, while one of the new residents, despite acknowledging they all have a right to self-medicate, explained he would not be able to manage his own medicines well and therefore was happy for the home to be in control of them. The Manager has introduced some new policies and procedures for staff to follow and produced some new aims to promoting independence amongst the residents, to improve the wellbeing of residents, which are being implemented. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 and 15. Residents lead the kind of lifestyle that they choose for themselves, involving social, cultural, religious and recreational interests. They enjoy excellent contact with family and friends, which is fully encouraged by the home. Residents have nourishing and appetising food, which is eaten in pleasant surroundings. EVIDENCE: There have been no changes to the systems or practices in the home since the last unannounced inspection and therefore evidence to standards 12, 13, 14 and 15 remains the same. Residents have freedom of choice and movement, make their own decisions, and receive visitors as they wish. New residents spoken to confirmed the freedom of choice they have in terms of food, activities, where they go and when, what they do and the decisions they make etc. This was observed throughout the inspection in respect of all residents. Those residents and two visiting relatives spoken to stated satisfaction with the food and care provided. Conversation with the cook revealed that the home has for the seventh consecutive year been awarded The Heartbeat Award for healthy eating and that everyone in the home is very proud of this. Standards are very high. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18. The residents are well protected by the home’s systems and practice for making complaints and reporting abuse, and staff are well informed and instructed in both areas. EVIDENCE: There have been no changes to the systems and practices for making and dealing with complaints or allegations of abuse since the last unannounced inspection and therefore evidence for standards 16 and 18 remains the same. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26. Residents live in a safe, well-maintained environment, which is clean, pleasant and hygienic. EVIDENCE: Observation of non-personal care practices within the home and viewing of four bedrooms revealed that staff maintain hygienic and safe practices, and that the home is clean, pleasant and homely. Staff informed the Inspector they use personal protective equipment when providing personal care, and are aware of the home’s policies on infection control etc. The laundry is well managed and maintained, and is safe and clean. The cleaners and staff adhere to Control of Substances Hazardous to Health (COSHH) information and regulations. The Manager has recently submitted to the CSCI, an annual return evidencing all safety checks on equipment in the home and when other agencies have visited for purposes of auditing safety practices. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 Page 13 There is some evidence, which remains the same as at the last unannounced inspection: fire safety records show the home meets the requirements of the local fire service, that checks are done weekly on the system, and that drills are held at least twice a year for each staff member who also complete fire training twice a year. Accident records are maintained in data protection format and any trends are identified and acted upon. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 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): 27, 28, 29 and 30. Residents have their needs met by a skilled and competent work force that is carefully recruited and selected, and well trained to do their jobs. EVIDENCE: There have been no changes to the systems and practices for recruiting and selecting staff since the last unannounced inspection and therefore evidence for standards 27 and 29 remains the same: the Manager and the staff confirmed the recruitment and selection procedure, and documents held in files acted as evidence it is followed. Documents included all items of proof of identity and suitability for the post, as required in schedule 2. Information received in conversation with the Manager and staff and from training files, revealed staff are a very skilled and trained workforce to care for older people. Staff have undertaken experiential training in such as dementia, ‘heart start,’ moving and handling, abuse awareness, etc. They are undertaking NVQ level 2 and 3, and intending to move onto level 4. The home currently has 72 of care staff with NVQ 2 and/or 3. Competence to care is always monitored by the Manager, who provides advice, support and many years experience. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 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): 31, 33, 35 and 38. Residents have the benefit of a highly experienced and suitably trained Manager to run the home in a way, which is in their best interests. Residents have their financial interests very well safeguarded. Residents’ and staff health, safety and welfare are very well promoted and protected. EVIDENCE: The Manager is at the end of her NVQ level 4 Registered Manager’s Award and should have completed it by the end of the month. She has many years experience of managing a care home, works very actively as an Elected Member of Hull City Council, and maintains current good practice through updating her knowledge and information via journals and publications. The Manager runs the home in the best interests of residents and operates a quality assurance monitoring system, which involves residents’ and staff meetings, visiting professionals’ and relatives’ surveys, and two monthly Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 Page 16 auditing of care practices and performance. All of this information is collated within a bi-annual report, posted in the home’s entrance. The home’s complaint monitoring system and internal auditing of residents’ finances also inform the quality assurance system. These systems inform the Manager of the areas requiring improvement in order to maintain residents’ satisfaction with the services they receive. Residents spoken to and willing to discuss generally about their financial affairs informed the Inspector they are satisfied with the systems for paying accommodation charges, holding personal allowance in safe-keeping and maintaining an amount of money on their person. Almost all residents’ finances are under the control of a relative. With the implementation of benefits being paid directly into bank and post office accounts, residents (and the home’s staff) have little to do with transactions for accommodation charges and are satisfied with personal allowances also going straight into their account. Family members are asked to ensure their relatives have sufficient funds in the home’s safe keeping facility to allow them to maintain small expenditures. One resident spoken to had some dissatisfaction with her personal financial circumstances and expressed the view her rights were being denied in respect of her benefit payments. This has nothing to do with the actions or practices of the home or staff. The Manager and staff adhere to requirements of standards and regulations in respect of health, safety and welfare of residents and staff. Policies and procedures are in place, legislation is adhered to, practices are informed by good practice guidelines, records and documents are kept up to date and risk assessments are compiled, implemented and reviewed. All mechanical and industrial machinery or equipment is appropriately maintained, checked and certificated, and both gas and electrical requirements are followed and documented. Evidence is maintained through records, certificate, and documentation. Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 Page 17 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 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 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 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 Page 18 No 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. 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 Lake View Manor DS0000000858.V265064.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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