Inspection on 21/11/05 for Lakelands

This inspection was carried out on 21st November 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lakelands 12/09/06

Lakelands 26/04/05

Lakelands 30/11/04

Lakelands 19/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Lakelands Grizedale Drive Higher Ince Wigan Greater Manchester WN2 2LX Lead Inspector Judith Stanley Unannounced Inspection 21st November 2005 09:30 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 Lakelands DS0000005775.V266705.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. Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lakelands Address Grizedale Drive Higher Ince Wigan Greater Manchester WN2 2LX 01942 323154 01942 826199 margaret.bennett@clsgroup.org.uk www.clsgroup.org.uk CLS Care Services Limited 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) Mrs Margaret Bennett Care Home 40 Category(ies) of Dementia - over 65 years of age (1), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (40), Physical disability over 65 years of age (8) Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include:up to 40 service users in the category of OP (Older People) up to 8 service users in the category of PD(E) (Physical Disabilities over 65) up to one female service user in the category of DE(E) (Dementia over 65) up to 2 service users in the category of MD(E) (Mental Disorder over 65) The service should employ a suitably qualified and experienced manager who is registered with the CSCI. One named service user (GH) may be accommodated in the category of DE(E) (Dementia over 65 years of age). Two named service users (LG and HS) may be accommodated in the category of MD(E) (Mental Disorder over 65). 26th April 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Lakelands Care Home is part of the CLS group of Homes. Lakelands is a purpose built two storeys home, which offers care for up to 40 residents with a variety of needs. The Home is situated on a housing estate set in its own grounds and is close to a local bus route and local shops. It is pleasantly situated in its own grounds and has attractive gardens to the front and rear with ample parking at the front of the Home. All rooms are single, there are no rooms with en suite facilities, however all rooms are fitted with a hand basin and bathrooms and toilets are close by. There is a passenger lift to the first floor. Lounges and dining areas are available on both floors. Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of 3 hours on one day. The first part of the morning was spent talking with, staff, residents and visitors as wall as making a tour of the premises. The remainder of the visit was spent talking with the manager and looking at some records the home hold on residents (care plans). In order to obtain information about the home, comment cards were sent to residents, relatives and other professionals (district nurses, GPs and care managers. The response to the questionnaires was low, however it should be noted that the home had recently completed a residents/ relative survey and the RDB inspection (company that issues the star rating for homes in the Wigan area) had also sent out a range of questionnaires to residents and families. What the service does well: What has improved since the last inspection? Since the last inspection the manager has completed the National Vocational Qualification (NVQ) award at level 4. Domestic staff have undertaken NVQ level 1 and are waiting to start on level 2 and two members of staff have had training in palliative care (care for people who are dying). It was noted that new chairs and blinds had been bought for the lounges downstairs and two new TVs, a DVD and video recorder had also been purchased. Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 6 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. Lakelands DS0000005775.V266705.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 Lakelands DS0000005775.V266705.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: None of the key standards were assessed on this occasion. These will be inspected at the next inspection. Lakelands DS0000005775.V266705.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 and 10 The records showed that health, personal and social care needs of the residents has been identified and reviewed. Residents could be confident they would be treated with respect and that their right to privacy and dignity would be promoted. EVIDENCE: Four care plans were looked at and contained all the necessary information to ensure the health, personal and social care needs of the residents could be fully met. Each record gave a brief outline of the individual person’s background, work history, family, hobbies and interests and likes and dislikes. This short profile helps staff to understand a little about the person to whom they are providing care for. The care plans were updated monthly and there was evidence to show that 80 of residents and some relatives had been involved in drawing up and maintaining information recorded in the care plans. Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 10 Risk assessments were in place for the four residents, including those related to moving and handling, prevention of fall, maintaining the quality of skin tissue and nutrition. Each plan is reviewed on a monthly basis. Where specialist equipment such as pressure relieving mattresses and cushions is required, these are generally provided through the community or hospital services. The focus of care at Lakelands centres on the individual. Respect for the independence, dignity, privacy, choice and fulfilment of each resident is carried out on a daily basis. Information taken from a recent survey within the home shows that from the 23 returned questionnaires all residents said that, they could get up and go to bed when they choose, they can choose how to spend their days, they are able to make decisions about what and where they eat. Residents were asked if staff respect and uphold their dignity, independence, rights and beliefs, all residents responded positively. These comments were reiterated to the Inspector during conversations with residents. Lakelands DS0000005775.V266705.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 and 14 The routines of daily living are flexible enough so that the different needs, expectations and preferences of residents are met. Residents are kept informed and are helped to maintain a good level of independence and to exercise control over their lives. EVIDENCE: It was clear from observations, from records and from conversations with residents that they are offered real choices about how they live their lives. The manager and staff produce a monthly newsletter that is informative and easy to read. There is also an information booklet “Living at Lakelands” which details the services and facilities available. To celebrate the 20th anniversary of the opening of Lakelands, residents and staff had a party at the home. With regard to activities, the homes survey and through conversation with residents it was noted that most residents were satisfied with the range offered, however further options from residents were suggested and the staff will endeavour to include these in the programme. Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 12 Residents spoke well about being able to maintain a good level of independence. Visitors confirmed were always made welcome and this was observed, for example, one visitor comes to the home a couple of times a week at lunch time and brings fish and chips in for himself and the resident. Visitors are welcome to help themselves drinks for the small kitchens on the floors. From a tour of the premises it was observed that residents bedrooms were warm, clean and tidy and had been personalised with their own belongings brought in from their own home. Lakelands DS0000005775.V266705.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 and their supporters can easily access the complaints procedure. The home has a satisfactory system in place with regard to the investigation of adult protection issues, ensuring that residents were listened to and protected. EVIDENCE: The home as a complaints procedure, this is suitable displayed in the home and in the welcome pack in each room. The feedback from the homes survey indicated that 26 of the residents did not know how to make a formal complaint, however all residents felt that if they had a suggestion or were concerned about any issues they would be comfortable to discuss this with the manager and appropriate action taken. This was confirmed in conversation with the residents. The home has a policy and procedure on the protection of vulnerable adults, and staff have received training through the completion of formal qualifications and in house training. Lakelands DS0000005775.V266705.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): 19 The standard of décor in parts of the Home is poor. The home does not therefore provide residents with a comfortable and homely place to live. EVIDENCE: The ground floor of the home is suitably decorated and looks attractive to residents and visitors. The first floor is in need of decorating; the manager, staff and residents spoken with were in agreement that the standard of décor on the ground floor is superior to the first floor. This is not acceptable, residents should be offered the same standards throughout the home. This was discussed at the last inspection, but no improvements have been made. Lakelands DS0000005775.V266705.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 Staff are properly trained to deliver the care that residents need. The practice of retaining two staff on duty overnight needs constant review to ensure residents’ needs are met. EVIDENCE: Training for staff is progressing well, all staff have either completed NVQ level 2 or have enrolled for NVQ level 2. Staff confirmed that during day an adequate number of staff is on duty, it was commented that early mornings can be exceptionally busy and staff felt that the residents would benefit from extra staff on duty. The practice of having two waking staff on duty for 40 residents still applies. The manager confirmed that if necessary, for example if a resident was ill and needed extra support, extra staff would be on duty. Lakelands DS0000005775.V266705.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): 33 and 38 The manager and staff work hard to maintain an open culture, where everyone is included and valued. The are systems in place to audit the service provision, so that improvements are made and poor practice is eradicated, in keeping with residents best interest. EVIDENCE: Staff describe a continuing good spirit and an open and trusting atmosphere. Feedback in the homes recent residents/ relatives survey conducted prior to the inspection is positive and encouraging. Opinions are actively sought from residents through meetings and day-to-day communication. Health and safety checks were satisfactory with regular maintenance checks on equipment for example fire systems and alarms and water temperatures. All Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 17 accidents and incidents were correctly recorded in the accident book. All staff have received health and safety training as required. Lakelands DS0000005775.V266705.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 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x 3 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 x x 3 x x x x 3 Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 19 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 OP19 Regulation 23 Requirement The first floor decor requires attention. (This requirement is outstanding from the last inspection 31/08/05) Timescale for action 27/01/06 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. Refer to Standard OP27 Good Practice Recommendations Numbers of night staff on duty to be constantly reviewed in order to ensure that all residents needs can be met. Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Lakelands DS0000005775.V266705.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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