Inspection on 02/02/06 for Lakeview

This inspection was carried out on 2nd February 2006.

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

Lakeview 17/10/07

Lakeview 22/02/07

Lakeview 22/05/06

Lakeview 08/08/05

Lakeview 01/03/05

Lakeview 13/09/04

Lakeview 08/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lakeview Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA Lead Inspector Mrs Joanna Wooller Unannounced Inspection 2 February 2006 9:15 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 Lakeview DS0000022331.V279408.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. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lakeview Address Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA 01922 409898 01922 403434 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) Alpha Health Care Limited Mrs Tracey Belinda Arms Care Home 151 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (53), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (10), Old age, not falling within any other category (25), Physical disability (123), Physical disability over 65 years of age (123) Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Physical Disability (PD) minimum age 60 years on admission Physical Disability (PD) minimum age 49 years on admission - 2 persons 1 DE - Named Resident minimum age 59 years on admission Date of last inspection 13th September 2005 Brief Description of the Service: Lakeview Care Home with Nursing, forms part of the Lakeside Site. The home is owned by Ralton Care Homes Ltd, Alpha Care Homes Ltd and was purpose-built during 1996/97. Lakeview is set within its own landscaped gardens and grounds amounting to over 5 acres. It is situated on the main A34 trunk road midway between Walsall and Cannock with a regular bus service stopping directly outside the home. Birmingham, Stafford, Wolverhampton, Lichfield and Brownhills are all within 20-30 minutes drive by car. The services offered by the home are: - Dementia, Mental disorder (excluding learning disability or dementia), Old age (not falling within any other category), Physical disability, Physical disability over 65 years of age. Lakeview has 151 beds and is divided on two floors served by three passenger lifts. Service users are accommodated in single rooms with en-suite facilities. There are a limited number of double/shared rooms, which would be ideal for married couples. The nursing and personal care areas are divided into separate corridors each with its own Head of care, team of nurses and care staff. The units were recently renamed to represent one of the lakes in the Lake District. These units are named as Windermere a 38-bedded residential Unit, Grassmere a 35bedded nursing unit and Buttermere a 25-bedded nursing unit. The 53 bedded mental health unit, Thirlmere is located on the second floor. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The lead inspector carried out this unannounced inspection accompanied by three support inspectors. The newly appointed manager was in the home and the Deputy care manager was in charge of the morning shift. There was a peaceful ambiance throughout the home. Some residents going about their usual routines supported by carers and nurses. The visit was uneventful and all requests from the inspectors were met. 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. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 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 Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 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): 2, 4, 5. Each resident had a contract signed; following a full pre admission assessment confirming their needs could be met in the home. Prospective residents and their relatives are invited to look around the home prior to making a decision. EVIDENCE: The documentation seen, and following a discussion with the residents and their representatives, the inspector evidenced that individuals had been assessed prior to admission and they had been enabled to make a choice about the home. All those involved had the opportunity to visit the home prior to choosing to stay. Several residents spoken to had visited the home prior to making a decision. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within some service user plans. Some service users confirmed that they had been fully involved and were in agreement with the assessments. This is one area that the manager wishes to develop in the near future. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 8 The records seen and a discussion with the staff evidenced that some care staff had the necessary experience and skills to meet the assessed needs of the current service users whilst other required further supervision, which had been already identified prior to the visit. Lakeview DS0000022331.V279408.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, 8, 9 The assessed health and personal care needs of service users had been documented and were felt to require developing further throughout most units in the home. There was a system for the receipt, storage, administration and disposal of medicines although a few issues were noted. There was evidence that individuals are treated with respect, privacy and dignity, during the caring process. EVIDENCE: The service user plans and associated documentation were in place. The documentation seen at the visit evidenced that health and personal care needs were being assessed. It was identified that further development within the records was required. The manager prior to the inspection had identified this area of development. Staff that were spoken to by the inspector were aware of the new aims and the general ethos of the home and felt that the new manager will assist them to achieve the levels expected of them. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 10 NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. During the inspection the inspector spoke to many service users who felt content with their life in the home and the care they received. It was observed by the inspector that the privacy and dignity of service users were being respected and there was very good interaction with all the staff. Care staff were seen knocking on doors before entering. Medication Issues There was evidence of medication being crushed on Thurlmere unit this was done with a pestle and mortar in the treatment room. Arrangements were being made for an alternative system. Medication had been left on the cupboard and that was due to the cupboard lock being faulty. Oxygen in the treatment room on Grassmere was not stored appropriately loose bottles were upright with no chains; some were full bottles. Lakeview DS0000022331.V279408.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 to 15 Lakeview generally provided a relaxed and friendly atmosphere. Residents who were able were observed to be moving freely around the home with a variety of activities being available. The menu was observed and the meals offered in the home were traditional and wholesome providing residents with choices at all mealtimes. EVIDENCE: Currently activities are recommencing across all the units Thurlmere, Windermere, Grassmere and Buttermere. Activities organisers are employed full-time on Thurlmere and part-time on the other three units. (Activities for E M I residents) training is being accessed for the activities organiser on Thurlmere. A weekly/monthly programme is displayed on all units identifying social opportunities available for individuals and relatives who wish to join in are encouraged to do so. All activities are geared to the pace or concentration spans of the individual and could be small group activities or one to one dependent on residents. Where possible meetings are held with residents and their relatives informally to discuss how the resident liked to spend their time. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 12 Residents maintain social contact with family and friends via visitors to the home a number who were visiting today. The inspector spoke to visitors whilst walking around the home and positive comments were made about the way residents are cared for. Community contact is maintained via visiting professionals to the home, entertainers, Pat Dog visits all units, which residents said they enjoy. Residents who are able and wish to do so go out into the community visiting the Theatre, shopping, pub meals, out with families. Hairdresser was visiting today. One resident goes out to Rushall Day Centre and said they enjoyed this. The home is developing “League of Friends” Inspector looked at menu this offered a variety of traditional food and choices at all mealtimes. Special diets are catered for as required and include soft food, diabetic, and liquidised food. Observations were made of both meals and drinks being taken around and of staff assisting residents in a sensitive way. Religious/cultural foods are catered for as necessary. Mealtimes are being adjusted to provide flexibility and breakfast will now start at 8.30 am offering healthy eating with a cooked breakfast being available if requested. Lakeview DS0000022331.V279408.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 to 18 The home has a satisfactory complaints system in place with some evidence that service users feel their views are listened to. The home has systems and procedures in place to ensure the protection of resident’s legal rights. EVIDENCE: Since the last Inspection there have been five formal complaints about the home. All have been investigated and where necessary action taken to deal with them. Two complaints were on Thurlmere, one on Buttermere, two on Grassmere. Several vulnerable adult meetings had been held and action had been taken to rectify the issues appropriately. Throughout all units resident’s rights are protected via relative’s involvement, solicitors, consultation with general practitioners as appropriate and power of attorney where necessary. Individuals are protected from abuse via staff training some staff have attended those that have not received formal training are booked on a course 7th February. These staff received induction training on abuse and a matrix has been started with a rolling programme of training now being developed. Any allegations of abuse staff are encouraged to report. All staff has CRB and POVA checks carried out. Lakeview DS0000022331.V279408.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 to 26 There were potential hazards for residents and staff from poor maintenance of flooring, equipment and from the inhalation of fumes from the clinical waste bins. Communal areas were comfortable; the majority of the lounges had a homely setting. There was a potential risk of a fire spreading with doors wedged/held open. EVIDENCE: Located on the busy A34, the home was purpose built to offer personal and nursing care to older people. The home divides into four units to meet the various needs of personal care/nursing. There were areas within each of the units that gave concern and were part of the feedback with the manager. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 15 While records identified that water temperatures were maintained, in Windermere there was no hot water in bathroom G2 wash hand basin; the water for the bath was under the recommended temperature. For the majority of the bathrooms the raised toilet seat attachments were loose and a possible hazard for the residents. G5 wash hand basin had a loose tap. Clinical waste bags were full and the aroma of ammonia overpowering in two bathrooms, this was attended to when requested. Bath seats and an area at the front of the sanitary ware were not acceptable and would benefit from a deep steam clean. A number of the bathrooms contained personal toiletries that should have been stored appropriately. In Thurlmere the cupboard in bathroom F3 was without a door and the cupboard in F4 required some form of locking devise. Windermere & Buttermere lounges have secondary heaters there is an urgent need to secure these heaters to prevent an hazard to resident and staff. King Arthur lounge door was wedged open plus some bedroom doors in Thurlmere this is poor practice and should cease. In the event a resident chooses to have a door open then the appropriate devise should be purchased. The fitting of such devises should be agreed with the Fire Officer. Within the dining room/lounge in Thurlmere there was an area of flooring where residents have their meals; this area was torn and parts of the flooring was standing proud. The inspectors were informed later that it had been secured. There is an urgent need to replace/repair this concern. Carpets in Thurlmere corridors were badly stained and discoloured black. The home had a section of equipment to ensure the comfort of residents when assisting movement. Bedrooms throughout the home seen had been personalised to suit individual tastes. The hygiene in the communal and bedroom areas was well maintained. It was pleasing to observe that corridors in Grassmere were in the process of being decorated. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 16 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 to 30 Staffing Notices were in place to ensure staff numbers were appropriate to the residents needs. Recruitment policies were in place. Staff training is to be reviewed to ensure that staff were suitably trained and skilled to do their jobs. EVIDENCE: The new manager is planning to review the staff skill mix and numbers to ensure that they are appropriate to meet the needs of the individual residents. Staffing structures are due to change. Staff supervision will be part of the review. The staff on duty on the day of the visit was in line with the Notice of staffing. The recruitment Policy and Procedure are being closely followed to ensure the right calibre of staff are employed in the home. Staff training and recording are also under review. The manager is concerned that the staff must be suitably trained, updated and informed of new practices in the home. Staff meetings are being arranged so that the staff are being fully informed. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 17 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, 36, 38 The home had the potential of being well run with the recent appointment of a manager that had the necessary experience and knowledge of managing nursing homes. The home had some quality assurance systems in place to monitor the service but the residents would benefit from the home developing these systems to provide them with a service that was fully monitored, reviewed and where plans were in place to develop the service. The home had suitable procedures in place to record residents’ expenditure ensuring that residents’ finances were safeguarded. At the current time the residents were not being supported by a staff group that was being appropriately supervised to undertake their role. Whilst the home had health and safety procedures in place the staff were not receiving the necessary training to be able to promote and protect the welfare and safety of residents. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 18 EVIDENCE: The manager had only been on post for three weeks and had not yet applied for registration with the CSCI. She did have the necessary experience having been a manager of nursing homes previously. She had also been a regional manager for a large company that ran nursing homes. She was aware of the issues of managing a large nursing home and had plans in place to develop the service and had already met with groups of staff to explain her plans for the future. The home did have some Quality Assurance checks in place including questionnaires of relatives and residents. The manager did have plans to develop the quality system through the introduction of a range monthly audits relating to environmental issues as well as care practices. A random sample of the way the home manages and records residents’ money was undertaken. This demonstrated that money was being kept securely in individual containers in the safe. Suitable records were being kept that fully identified the receipt of money and how it was spent. The home was keeping receipts to support expenditure. Checking of two accounts showed that the records corresponded with the cash held. Discussions with a number of staff took place over their supervision to undertake their role. These staff stated that they were not receiving any individual supervision and the management of the home confirmed this was the case. It was stated that supervision had dropped away of the last six months. The home had health and safety procedures in place and had a range of risk assessments in place for safe working practices although these were not present for the use of the COSHH products. The home employed a fulltime staff member responsible for maintenance and ensuring that all servicing and checks were completed. The records showed that all the necessary checks on fire equipment and fire prevention was being done including weekly fire alarm tests and monthly checks on the emergency lighting. Servicing was being completed on hoists and on the lifts. Plans were in place for the servicing of the wheelchairs. The home had a valid gas safety certificate and the electrical installation checks was up to date. Checks were being completed on the temperature of water and these were within the accepted temperature range. However random checks of some temperatures showed them to be outside of the accepted range. The home ensured that all hot surfaces were covered. The premises were secure. The home was completing records of accidents. The home had provided training in health and safety practices but there were a number of staff that had not received the training. One staff had not received any fire training for two years. The home had procedures in place for the storage and use of hazardous substances but a staff member was unaware of the procedures. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 19 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 3 X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 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 3 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 2 Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 20 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. 2. Standard OP8 OP27 Regulation 14 (2 a/b) 18 (1a) Requirement Service users needs are to be kept under review and altered as necessary. Management are to review that at all times there is appropriate numbers of staff on duty to meet the assessed needs of the service users. Records are to be maintained fully with relation to training and care records. All parts of the home where service users have access must be kept free of hazards. The registered person shall having regard to the size of the home and needs of the residents ensure that the home is of sound construction and kept in a good state of repair internally. Staff Supervision must be resumed Suitable Quality audit systems are to be put in place. To ensure that staff receive training relating to Health and Safety practices including fire safety, moving and handling, DS0000022331.V279408.R01.S.doc Timescale for action 01/03/06 01/03/06 3. 4. 5. OP37 OP38 OP19 17 13 (4a) 23 (2)(b) 01/03/06 03/02/06 01/03/06 6. 7. 8. OP36 OP33 OP38 18 (2) 24 18 01/04/06 01/04/06 01/04/06 Lakeview Version 5.1 Page 21 nfection control, food hygiene 9. OP37 13(4) Risk Assessments are to be put in place for safe working practices with hazardous substances. Staff must be trained and competent to do their jobs. Unqualified Staff are to be suitably trained with NVQ status Medication policies and procedures are adhered to. The registered person shall make suitable arrangements to prevent infection, and spread of infection in the care home. Time scale one week 09/02/06 10. 11. 12. 13. OP30 OP28 OP9 OP26 18 (1a) Sch2 (4) 13(2) 13 (3) 01/04/06 01/04/06 03/02/06 17/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 7 and 8 Good Practice Recommendations That development of a new care recording and system and relevant documentation is instigated as soon as possible to ensure the records evidence that individual needs are being met. Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Lakeview DS0000022331.V279408.R01.S.doc Version 5.1 Page 23 - 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!