CARE HOMES FOR OLDER PEOPLE
Lake View Rest Home 10/12 Lake Road Fairhaven Lytham Lancashire FY8 1BE Lead Inspector
Mrs Lillian McMullen Unannounced Inspection 23rd February 2006 10:30 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 Rest Home DS0000064226.V284812.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. Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Lake View Rest Home Address 10/12 Lake Road Fairhaven Lytham Lancashire FY8 1BE 01253 735915 01253 735915 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) Lakeview Rest Homes Ltd Miss Sarah Williams Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service is registered for a maximum of 29 OP (Older People 65 and over) service users 11th August 2005 Date of last inspection Brief Description of the Service: Lake View is registered to accommodate 29 service users aged 65 yrs and above of both sexes. The home provides excellent environmental standards, all rooms are single and all have bathroom en suites facilities. The home provides personal care and consults with G.P.s and district nurses regarding the medical needs of the service users. The facilities within the home are good. A passenger lift is in place that allows for independent movement between floors. Access in and out of the home can also be achieved independently as there are no steps to negotiate. A programme of activities is in place and the management and staff encourages, social stimulation, both in and outside the home. Transport is always available for outings and trips either for group events or for individual shopping trips or to keep appointments. The hairdresser visits weekly and arrangements are made for the chiropodist, dentist and optician to visit the home if the service users are unable or do not wish to access community resources. Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out by two inspectors it was conducted over a period of four hours. The Inspectors spoke to a number of residents, the manager, the cook, and a number of staff. The inspection focused on assessing the standards that were not assessed at the previous inspection. This involved looking at the medication procedures, the quality of meals and social activities. What the service does well: What has improved since the last inspection?
Good systems are in place and the manager continues to look for ways that can develop the service further. An up to date training matrix has been developed which records the training undertaken together with the date of when refresher courses are due.
Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 6 The registered manager is now including details of resident’s life history into the care documentation, which will provide staff with some insight into the resident’s interests and personal preferences. 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 Rest Home DS0000064226.V284812.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 Lake View Rest Home DS0000064226.V284812.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): EVIDENCE: All of the above core standards were assessed at the previous inspection. Lake View Rest Home DS0000064226.V284812.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): 9 The medication procedures ensure that residents receive medication as prescribed. All medication is stored securely. EVIDENCE: The administration of medication was, observed by the inspector this was carried out at the lunchtime meal. Medication was administered directly from the pharmacists packaging and the staff member observed the medication being taken. Records were seen to be clearly written and medication was signed for at the time of administration. Controlled drugs were stored separately and signed for by two staff members, however on checking the medication against the record it was evident that the stock did not correspond with the record, in that there ware three tablets two many. The inspector advised that the additional tablets be retuned to the pharmacy and the record amended and signed. Systems must be put into place to effectively monitor the administration and recording of controlled drugs.
Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 10 All prescriptions are now viewed prior to being dispensed and all medication is recorded as it arrives in the home. It was evident that a good stock control system is in place as only medication in use is held. Lake View Rest Home DS0000064226.V284812.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): 12,13,14 and 15 Social activities and meals are well managed to suit both the individual and group. Contact between residents and their families’ is encouraged to help maintain relationships. EVIDENCE: From observation and discussion with the cook evidence was found to confirm that the meals served were nutritionally balanced with a varied menu provided. The dining room is pleasantly decorated and provides a comfortable environment for residents to enjoy their meal. Meals were unhurried and the inspectors noted that residents were afforded time to eat their meal at their own pace. The meals were well presented and looked appetising and special diets are catered for. All residents spoken with said that they enjoyed their meals and that a choice was always available. A range of activities are arranged which include trips out to local shows and attractions, in addition staff will escort residents on a one to one basis if they want to attend a family event or go shopping. At the time of the inspection the local vicar was in the home providing communion to a number of residents.
Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 12 The registered manager informed the inspectors that every effort is made to support residents to follow there preferred religion. There are no restrictions on residents and they are free to come and go as they please. One resident enjoys her own company and the registered manager stated that no pressure is applied for her to join in communal activities. Visitors are welcome at any time and residents can entertain their guests in the privacy of their own room. Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 13 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 Residents are protected by a robust policies and procedures that enable concerns to be raised and responded to and to protect residents from abuse. EVIDENCE: The home has a comprehensive complaints procedure, which is contained in the Service User Guide and provided to residents and their relatives upon admission. The home has received no complaints since the last inspection. The Commission for Social Care Inspection has received no complaints within the last year and there have been no vulnerable adult referrals to Social Services. Whilst there have been no recent complaints the inspector did offer some advise, in that the complaints procedure would be further improved if forms were freely available for residents and their relatives to comment on the service provided. The home has an abuse policy in place, which includes guidance on whistle blowing, abuse by residents and advice for staff regarding challenging behaviour. This policy is easily accessible by staff and is compliant with the D.O.H. guidance ‘No Secrets’. The training matrix maintained provided evidence that all staff have received training in the protection of Vulnerable Adults. Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 14 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): EVIDENCE: All the above core standards were assessed at the previous inspection. Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 15 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): 28 Training is viewed positively and staff are provided with opportunities to ensure they have the knowledge and skills to meet the needs of the residents. EVIDENCE: The registered manager supports staff in all forms of training, at present seven staff members have attained a NVQ qualification with a number of other staff members currently undertaking this qualification. It is pleasing to note that the home has achieved in excess of the required 50 of the total staff group that now are appropriately trained. Induction training is provided and commences on the first day of employment by new staff being informed of the home’s safety procedures together with an introduction into the home’s policies and procedures and continues by working alongside an experienced member of staff. All new staff follows the TOPSS induction programme, which once completed staff, are then expected to embark on NVQ training. Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 16 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 The management and staff at the home are competent. Resident’s finances are protected. The health, safety and welfare of residents is strongly promoted. EVIDENCE: The registered manager is competent and experienced to run the home she has a number of years experience and is committed to supporting staff in order that the residents receive the best possible care. The registered manager is currently working towards achieving a National Vocational Qualification Level 4 award in care. In addition, the registered manager is keen to undertake additional training in order to build on her existing skills and knowledge. It was clearly evident from observation that there is a good rapport between residents, and staff that helps to create a sense of belonging. Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 17 Staff members were very positive in their comments about the registered manager and the support she provides. One staff member stated, “the manager is really good she will do whatever she can to make sure the residents have everything they need”. Quality monitoring systems include internal systems, which invite feedback from people living at Lake View Care Home and their relatives in the form of anonymous questionnaires being issued twice a year. The findings of the questionnaires then inform how improvements to the service are to be implemented. In addition the home has achieved the Investors in People award. Inspection of records for residents showed these were comprehensive, well written and up to date. Records of money being handled by the manager for residents were up to date, explaining the reason for any expenditure and the balance of the money that was being retained. Health and safety policies are in place and all staff receives training in all mandatory subjects, which include health and safety, first aid, infection control, fire safety and food hygiene. The home is maintained to a good standard and no hazards were apparent at the time of the inspection. The homeowner and manager have a continuous programme of redecoration and refurbishment to ensure standards are maintained. The inspector advised that arrangements would be made to forward the preinspection questionnaire and requested the manager to complete this document confirming that all safety equipment is regularly serviced. Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 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 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 19 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. 1. 2. Refer to Standard OP9 OP16 Good Practice Recommendations Controlled drugs must be closely monitored to ensure the record of administration correctly corresponds to the stock held. Forms could be made available to allow for residents and relatives /visitors to freely comment on the service. Lake View Rest Home DS0000064226.V284812.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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