Inspection on 08/08/05 for Lakeview

This inspection was carried out on 8th August 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

Lakeview 17/10/07

Lakeview 22/02/07

Lakeview 22/05/06

Lakeview 02/02/06

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 Joanna Wooller Unannounced 8 August 2005 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. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lakeview Address Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA 01922 409898 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) Alpha Health Care Ltd Mrs Tracey Belinda Arms CRH 151 Category(ies) of DE- 1 registration, with number DE(E) - 53 of places MD(E) - 10 OP - 25 PD - 123 PD(E) - 123 Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) Physical Disability (PD) minimum age 60 years on admission 2) 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 1 March 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 seperate 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 35 bedded nursing unit and Buttermere a 25 bedded nursing unit.The 53 bedded mental health unit, Thirlmere is located on the second floor. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was made on 8th August 2005 at 08.00hrs. Three inspectors using the National Minimum Standards for Older People as a reference undertook the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 12hrs. The deputy care manager, Karen Beale was in charge of the home and Margaret Lawless the Area Manager for the home was also present. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with several service users, discussions with all the staff members on duty, observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing levels, quality assurance and health & safety. Since the last inspection on 1st March 2005; there had been no changes to the management of the home, three complaints had been received by the CSCI and additional visits had been necessitated to investigate these issues. Several strategy meetings had taken place re vulnerable adult situations but none were substantiated. The inspectors evidenced a busy morning in the home, the carers were serving breakfast and the trained nurses were dispensing medications. Aspects of care were evidenced to be given respecting individual wishes. Service users had been able to choose the home following an assessment and invitation to visit the home. Service user plans were hand written, and some were based on the community care plans completed by social workers. Health, personal and social care needs had been identified and documented. One complaint had been received since the last inspection and the complaints team was dealing this with. The home was seen fit for purpose and provided a safe environment for the service users and staff. The premises were clean and generally tidy. The domestics had commenced their usual daily routine. Adequate areas for service users were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities, including catering and laundry, were adequately provided. Health and safety aspects had been given a high priority and no shortfalls were noted. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 6 Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. However some staff on the nursing unit felt under pressure and the deputy manager was going to reassess the dependencies. Staff training had been given a priority but the records were incomplete and this was to be attended to. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Assurances were given to the inspector regarding the positive financial viability of the home, and that suitable accounting/business procedures were in place. A recent position had become available for a Human Resource Manager on site and this had been filled. What the service does well: What has improved since the last inspection? What they could do better: • The training records were not concise enough for such a large work force. It is essential for the management to be confident that all statutory training is completed and other applicable training is fully documented. Care records must be precise and well documented. Some maintenance issues were identified and highlighted to the management: Toilet seat missing, floor buttons to be identified in lift and some repainting in knocked areas. • • 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 E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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 Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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) 3 Individual health, personal and social cares needs had been established and were being met by staff, which individually and collectively had the necessary skills and experience. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 9 EVIDENCE: The documentation evidenced on the inspection, and talking with service users and representatives, enabled the inspector to be assured that service users had been assessed prior to admission and they had been enabled to make a choice about the home. All service users and representatives involved had been given the opportunity to visit the home prior to choosing to stay. Several service users and their relatives spoken to had visited the home, and had a meal prior to deciding to stay, and this was documented within the care plans. Community care plans were provided by the social worker, as part of the individual needs assessment process. Service users representatives when asked were able to confirm that they had been fully involved and were in agreement with the assessments. The care records seen and a discussion with the staff evidenced for the inspector that the care staff, individually and collectively, had the experience and skills to meet the assessed needs of the current service users. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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 and 9 The assessed health and personal care needs of service users had been well documented and were being met, with good standards of care being delivered. There was a safe system for the receipt, storage, administration and disposal of medicines. Service users were treated with respect, privacy and dignity, during the caring process. EVIDENCE: Relatives spoken to on the visit all commented positively about the care being provided. The service user plans and associated documentation were hand written and generally reflected the current condition of service users. The documentation seen was not up to date on Thurlmere unit as it had not been updated monthly as the standard requires. Personal care needs were evidenced as being well met. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 11 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 in the care records. A local GP practice and pharmacist service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. No issues were raised relating to medicines within the home. The inspector observed that a safe system of administration of medicines was in place, and that the comprehensive medicines policy documentation seen was being complied with. Privacy and dignity were evidenced as being afforded to service users, and there was good interaction with staff. Care staff was seen knocking on doors before entering. One lady spoke to the inspector for some time regarding her views of the care home. She was escorting her Mother on a hospital visit and had been asked by the staff to attend with her. She felt the home had improved generally and that most of the staff was very committed. She felt they were under paid for all they did and she understood that it was a problem nationwide. She felt content that her mother was well cared for, she visited daily and if she had any concerns she raised them with the manager on duty before she left the home. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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) 12 to 15 Service users spoken to were satisfied with their lifestyle in the home, and they had been able to exercise choice and influence decisions affecting them. Contact had been maintained with relatives and friends of residents. Catering aspects were very good with balanced nutritious meals being served, along with individual consultation and choice. EVIDENCE: Contacts had been maintained, where possible, with relatives and friends and this was seen documented. Service users spoke of their visitors. Trips out to the community had been organised and transport provided. The staff showed the inspector the activities pictures and folder, which evidenced the activities both inside and outside the home. Several service users spoke of the places visited and also the entertainment within the home. Service users were seen to be enjoying breakfast at the time of this inspection they talked about their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of individuals were met. The cook when asked said that fresh good quality food from local suppliers was delivered on a weekly basis, the records seen confirmed this. The cook was Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 13 seen baking and preparing pastry, fresh vegetables and fruit were also seen. The inspector was able to evidence the daily delivery of fresh produce whilst in the kitchen. Service users unable to make a decision regarding choice of meals, due to their current condition, were assisted by staff who were knowledgeable of their individual likes and dislikes. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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 and 18 The complaint procedure displayed stated the procedure. Recoded identified that complaints were dealt within the time scale by the management. The staff was aware and had instruction for reporting suspected abuse. EVIDENCE: The records for complaints brought to the notice of the management had been dealt with and addressed with the families. The Commission had received three complaints; two had been upheld and the remaining was to be investigated. There was a complaints procedure posted in the front entrance hall. It was suggested that the management consider either posting a copy of the complaints procedure in each unit or a notice to refer to the main procedure. The service users and the staff spoken with were aware of whom to speak to in the event they had a concern. Staff confirmed that they had received training in elder abuse, the inspectors were told by the management that this would include POVA awareness. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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, 20, 22, and 26 The Lakes had a suitable attractive environment that provided a comfortable home for residents. Service users and the staff could be better protected with the appropriate equipment located for easy use. Service users need to be protected by a safe environment maintained in the bathrooms. EVIDENCE: Located on the busy A34, the home was registered to provide care to older people with various and complex needs. The garden at the rear of the home was well maintained; service users in Windermere unit appreciated the colourful flowerbeds. The concerns regarding the poor bed making were observed to have improved on this visit. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 16 Three of the bathrooms on Windermere were evidenced during the inspection today. Each one was untidy, there was no evidence of protective gloves or aprons for the protection of the residents and staff, and G4 bathroom was being used for storage purposes. Items that could be hazardous to residents had been left in the bathrooms. The sluice on the ground floor was full of boxes, this facility could not be accessed; the light was also inoperable. Observed on the floor in the bathroom near to the Queen Mary Lounge was a box of new catheter bags. These bags would have been prescribed to a service user. They could now be contaminated. Specialist equipment was observed to maximise individuals’ independence; the home had provided collective equipment for general use. A sample of the bedrooms on the ground floors and within other parts of the home was observed to be personalised to suit the occupant. Within the Queen Mary lounge there was an unstable heater, which was brought to the notice of the management at feedback. The fire doors to this lounge negated the fire requirements by not closing correctly. The home is clean and maintained in a pleasant condition. The large laundry was located on the ground floor. Staff explained their rota and work and their awareness of COSHH when handling soiled linen. Outside the laundry there was a number of items including mattresses, and old chairs, the inspector was told that a skip had been recently collected. It is important that these items were removed as soon as possible. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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 and 30. The assessed needs of service users were identified in some areas of the home to need reassessing to ensure adequate number of suitably trained staff is on duty. Recruitment procedures had been correctly addressed which had contributed to the protection of service users. Staff training had been given a priority but it was identified to need collating appropriately into a training record. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 18 EVIDENCE: The duty rosters were seen by the inspector, and a discussion with the staff, evidenced that in some areas of the home adequate numbers of staff were not on duty to meet the needs of the existing service users. The deputy manager was to reassess the dependencies of the individuals and look at the working routines of staff. The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Training had been given priority and the training records of individuals were seen. The records evidenced that staff had benefited from ‘in house’ and external training which had covered the needs of the registered client group. Staff told the inspector that they had been encouraged to study. Training had been provided for staff in the awareness and management of dementia related conditions. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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, 33, 37 and 38. The home appeared to be well managed and quality assurance was in place. Financial aspects were correctly addressed and recorded with safeguards to residents. Health and safety issues had been given priority and managed well. EVIDENCE: From observations made, discussion with service users, and discussions with the deputy manager and staff, it was evident that the home was being run in the interests of service users. Quality assurance and regulation 26 visits were seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 20 Health and safety issues were noted during this inspection during a tour of the home. • Inappropriate storage has caused hazards in bathrooms and corridors. The documentation seen for checks and examination of plant and equipment was all correct and up to date. The deputy manager and staff spoken to confirmed that health and safety issues are given priority. Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 2 2 Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 22 Yes 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. 2. Standard 8 27 Regulation 14 (2 a/b) 18 (1a) Requirement Timescale for action 1 Month 3. 4. 37 38 17 13 (4a) Service users needs are to be kept under review and altered as necessary. Management must ensure that at 1 Week all times there is appropriate numbers of staff on duty to meet the assessed needs of the service users. Records are to be maintained 1 Month fully with relation to training and care records. All parts of the home where 1 Week service usres have access must be kept free of hazards. 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 Good Practice Recommendations Lakeview E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Stafford - 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 E51-E09 S22331 Lakeview V241290 080805 Stage 4.doc Version 1.40 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. 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