Inspection on 26/04/05 for Lakelands

This inspection was carried out on 26th April 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 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

Lakelands 12/09/06

Lakelands 21/11/05

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, Manchester WN2 2LX Lead Inspector Judith Stanley Announced 26 April 2005 10:00 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 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 F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lakelands Address Grizedale Drive Higher Ince Wigan Greater Manchester WN2 2LX 01942 323154 01942 826199 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CLS Care Services Limited Mrs Margaret Bennett CRH Care Home 40 Category(ies) of DE(E) Dementia - over 65 : 1 Place registration, with number MD(E) Mental Disorder - over 65 : 2 Places of places OP Old Age : 40 Places PD(E) Physical Disability - over 65 : 8 Places Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 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) 2. One named service user (GH) may be accommodated in the category of DE(E) (Dementia over 65 years of age). 3. Two named service users (LG and HS) may be accommodated in the category of MD(E) (Mental Disorder over 65). 4. The service should at all times employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. Date of last inspection 30 November 2004 Brief Description of the Service: Lakelands Care Home is part of the CLS group of Homes. Lakelands is a purpose built two storey 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 facilties, 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 F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted over a period of six hours. The first hour and a half was spent talking with the manager about the running of the Home, staff training and development and any planned changes. The Inspector looked around the building and spoke with members of staff and resident’s. Some care plans and records were checked as well as looking how the medication was given out and how the recording of the medication was completed. In order to gather information about the Home, the manager, 8 residents, 4 staff, the activity coordinator, the cook, the laundress were spoken to. In addition 8 service user comment cards were returned and one from a care manager. What the service does well: What has improved since the last inspection? The resident’s information guide has been reviewed and updated to offer more detailed information about what it is like living at Lakelands and the services and facilities available. Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 6 Progress has been made by the manager to make sure that comments made at the last inspection regarding the decoration had been done. The ground floor of the Home has been decorated and residents spoken with said how nice the Home looked. The manager now sees all the regularly on an individual basis to talk to them abut their job and how they do it. All formal meetings with staff was suitably recorded. The manager has improved the information guide for people who want to know about the admission into the Home and about the services available. This information is available in all bedrooms for residents and relatives to read. 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 F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 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 standard(s) 1,3 & 4. Standard 6 is not applicable as intermediate services are not provided at Lakelands. The Statement of Purpose and Service User Guide are comprehensive providing residents and prospective residents with details of the services the Home provides enabling them an informed decision about admission to the Home. Pre admission assessments are good and formed the basis of the resident’s plan of care to ensure that those admitted could be adequately cared for. and EVIDENCE: The Statement of Purpose and Service User Guide have recently been reviewed to include all the necessary information. The guide “Living at Lakelands” provides details of the management structure, staff qualifications and their experience and training. The guide includes details of the facilities and range of services offered. The guide is available in all resident’s rooms for residents and relative to read and is made available to prospective residents. There was a good assessment system in place. The manager or the care team leader visits each person either at home or in hospital whether they were paying for themselves or being paid for by the local authority. The assessment Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 9 checklist was detailed and covered all the necessary areas to ensure that the Home and staff could meet all the resident’s needs of care as required. The manager confirmed that if a resident had been admitted to hospital from Lakelands, and was due to be discharged back to the Home that another assessment would be carried out to make sure that the Home and staff could still meet the assessed needs of the resident. Four members of staff spoken with were aware of the different needs that residents had including their personal care needs the support and assistance required, and their likes and dislikes. Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 There was a detailed, consistent care planning system in place, incorporating monitoring and reviewing arrangements and providing staff with the information they needed to meet the residents’ needs. The health care needs of the residents were met and evidence was available to demonstrate the involvement of other professional agencies as necessary. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure resident’s medication needs are met. EVIDENCE: The care plans were detailed and included all the information gathered during the initial assessment process. Each plan set out the aspects of health; personal and social care needs of the resident, and showed any amendments made to the original care plan. The monthly review and update had been completed as required. Risk assessments were in place in all the files inspected. They covered areas such as nutrition, pressure areas, moving and handling and falls. Entries in the care plan were clearly written, and those plans seen at this inspection, where possible had been signed by the resident or their representative. One Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 11 resident spoken with knew she had a care plan and that she could read it if she wanted. She had been consulted in the drawing up of the plan and with any changes made. The health care needs of the residents were met and evidence was available to demonstrate the involvement with other teams, for example the district nurses and physiotherapist as required. Feedback from a care manager who regularly places residents at Lakelands indicated that she was very happy with the care given to her clients and felt that staff were very able to meet the needs of the people she had placed there. The residents spoken with said they were happy with the care provided and that they felt well cared for by the staff. Staff who administer medication have received appropriate training. Medication storage and records were inspected and found to be maintained in an orderly manner. Individual drug sheets had been completed after each medication round. Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 & 15 Links with family and friends and with the local community are good and enrich resident’s social opportunities. The meals in this Home are good, offering choice and variety, and catering for special dietary needs. EVIDENCE: Three residents spoken to said they could choose where to see visitors either in the lounge or their bedroom. There is a small kitchen area with coffee and tea making facilities for relatives to help themselves to drinks as required. The Home maintains links with the local community and visits from local churches take place monthly. The Home produces a monthly magazine for residents and their families to inform them about what’s going on in the Home and forth coming events, which they are all welcome to attend. During the inspection no visitors were at the Home and the Inspector has not received any returned comment cards, although the manager confirmed they had been made available. Four residents spoke about the quality of food they said they were satisfied with the meals served and the different choices available. One resident said, “the meals are always good, its always hot and plenty of it”. One resident Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 13 confirmed that she could get up in the morning when she wanted as breakfast was served over a period of time. A lighter lunch was served and full cooked dinner, late afternoon is offered. Residents and staff were seen chatting together over lunch, which was seen to be unhurried and relaxed. Hot and cold drinks and snacks were available throughout the day and residents were offered a scone and strawberry cream tea mid afternoon, which one resident described as “delightful”. The manager confirmed that there was a set menu, which was seen to be varied and nutritious, however, it was subject to change and resident’s requests. The cook confirmed that special diet could be catered for, for example diabetics or for residents who required a soft or pureed diet. Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The Home has satisfactory systems in place with regard to the investigation of complaints or adult protection issues, ensuring that residents were listened to and protected. EVIDENCE: A complaints procedure was in place, which the manager confirmed is discussed on admission with residents and their relatives. In addition the procedure was detailed in the service user guide, which is available at all times and copies were observed in residents own rooms. A central complaints file is maintained, examination of the file showed there had been no complaints since the last inspection and the CSCI (Commission for Social Care Inspection) had not received any complaints about the Home. The Home has a policy and procedure on the protection of vulnerable adults, and staff have received training through the completion of a formal qualification and annual training and updates for all staff is mandatory. There have been no issues of concerns regarding the protection of residents living Lakelands. Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,24 &26 The standard of the décor in parts of the Home is poor. The Home does not therefore provide residents with a comfortable and homely place to live. The Home was clean, tidy and free from odour. EVIDENCE: Residents and staff were pleased with the new décor on the ground floor of the Home, however the manager feels the first floor requires the same attention and will discuss this with her manager. Bedrooms were seen to be comfortable and it was evident that residents had brought with them from home some of their own personal belongings, ornaments and photographs. Policies and procedures were in place with regard to infection control and staff were observed following correct procedures with regard to hand washing between tasks. Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 16 A walk around the premises, including lounges, dining areas, bathrooms, toilets and bedrooms showed a good standard of cleanliness and no odours were detected. Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 & 30 Staff morale is high resulting in an enthusiastic team that strive to offer good standard and continuity of care to all residents. Staff are trained and competent to deliver the care needed. The practice for retaining two staff on duty overnight needs constant review to ensure residents’ needs are met. EVIDENCE: Several staff had worked at the Home for many years; this provides residents with continuity of care. One resident commented that she had lived at the Home for a good number years and had seen many changes with managers and staff. She complimented the present manager and her staff for their care and commitment towards the residents, she described them as “dedicated”, “polite” and “very caring”. Staffing levels during the day and early evening were seen to be adequate, however there are only two staff on duty during the night for up to 40 residents with varied needs. The manager confirmed that if necessary, for example if someone was ill and needed support extra staff would be on shift. The Home has suitable staff recruitment procedures in place. Written application, references and a Criminal Records Bureau check (CRB) are obtained before a new member of staff starts to work at the Home. These are kept on individual staff files. All new staff completes a full induction within 6 weeks of their appointment to their post. Staff confirmed that they receive regular training and the manager has produced training programme for 2005, which includes fire training, infection Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 18 control, dementia care, schizophrenia, moving and handling and the protection of vulnerable adults. Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35 & 38 The manager is suitably qualified and experienced and runs the Home well. A satisfactory accounting system was in place that safeguards resident’s interests. All staff has received mandatory health and safety training to protect themselves and residents from potential risk. EVIDENCE: The manager is suitably qualified and very capable in her managerial role. The manager has many years experience in working with and caring for the elderly and could demonstrate a clear understanding of the needs of the residents in her care. Staff spoken with said the manager was very approachable and supportive to staff. The Home has suitable arrangements in place for dealing with resident’s personal allowances, which is normally used for visits to the hairdressers, shopping and toiletries. Residents who wish to keep their money with them are free to do so. All money is held individually and securely stored. Balance Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 20 sheets were completed to ensure there are no errors involving resident’s money. Health and safety checks were satisfactory with regular maintenance checks on equipment for example, fire systems, and fire alarms, making sure the hot water is not to hot for residents. All accidents and incidents were seen to be recorded correctly in the Home’s accident book. Staff training was seen to be ongoing with regard to health and safety in order to protect the welfare of residents and staff. Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x 3 3 x x 3 Lakelands F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 22 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. 1. Standard 19 Regulation 23 Requirement The first floor decor requires attention. Timescale for action 31/08/05 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 27 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 F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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 F56 F06 S5775 Lakelands V213729 260405 Stage 4.doc Version 1.30 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!