Inspection on 20/03/07 for Walmer Lodge

This inspection was carried out on 20th March 2007.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Walmer Lodge 25/10/07

Walmer Lodge 20/09/06

Walmer Lodge 08/12/05

Walmer Lodge 05/05/05

Walmer Lodge 26/11/04

Walmer Lodge 09/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Walmer Lodge 6 Walmer Villas Manningham Bradford West Yorkshire BD8 7ET Lead Inspector Karen Westhead Key Unannounced Inspection 20th March 2007 07:30 Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 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 Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 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 Adults 18-65. 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. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Walmer Lodge Address 6 Walmer Villas Manningham Bradford West Yorkshire BD8 7ET 01274 499338 01274 499338 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) Mr Suleman Ahmed Chunara Mr Sikander Khan Mr Salihu Tifin Shehu Care Home 12 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (12) of places Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2006 Brief Description of the Service: Walmer Lodge is privately owned. It is in the Manningham area of Bradford, approximately one mile from the city centre. The home can be reached by public transport. The home is registered to care for twelve residents who may have learning difficulties or a mental illness. All bedrooms are single. There is no disabled access to the building or passenger lift, to the bedrooms on the upper floors, therefore the home would not be suitable for residents who cannot manage stairs. There is a small garden to the front of the property, which allows parking for two cars. There is further car parking behind the home but this is not used, as the access through is narrow. The fee is £339.92 per week. This fee includes all toiletries, hairdressing, newspapers supplied by the home and chiropody treatment. The manager provided this information in June 2006. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was done by one inspector and had not been prearranged with the Manager. The inspector arrived at 7.30am and left at 2.30pm. At the end of the visit, the manager was told how well the home was being run and what needed to be done to make sure the home meets the standards. The reason for the visit was to make sure the home was being run for the benefit and well being of the residents and in line with requirements. Before the inspection information received about the home was reviewed. This included the number of reported incidents and accidents, the action plan provided following the previous inspection and reports from other agencies such as the fire safety officer’s report. This information was used to plan the inspection visit. A number of records were looked at during the visit and all areas of the home were seen. The inspector met with staff and residents to find out what it was like to live and work at Walmer Lodge. Comment cards and post-paid envelopes were left for residents and visitors to complete at a later date. Any comments received will be reviewed and if necessary acted on. Three residents completed their comment cards during the visit. What the service does well: What has improved since the last inspection? The owners have gone some way to safeguarding residents money however further evidence is needed to make sure the system being used is right. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 6 Staff have made improvements in record keeping, including risk assessments and care planning. Pans have been provided in the kitchen and some new carpets have been fitted. Staff meetings are now being held as a matter of routine every two months. 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. The summary of this inspection report can be made available in other formats on request. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are fully assessed before they are admitted to the home. EVIDENCE: Pre-admission records were looked at. These identified the type of care and support each resident requires. There were details, in some files, of discussions with the resident, other professionals, the carer and family members where appropriate. This shows that staff do not write these without the involvement of others who know the resident. Therefore information is accurate and reflects the resident’s needs. A senior member of staff is involved in the assessment of any prospective resident. Most referrals are made by a social worker, who provides the initial report when requesting a place at the home. The admission process allows for an introductory visit and if the resident is happy to proceed, and the staff can provide the support required, they are invited to stay for short periods or further day visits according to their circumstances. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 9 At the point of admission, each resident is given a contract that sets out the terms and conditions, the fees, and the room allocated. A sample of these were seen on residents files. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care needs that relate to behaviour and risk are carefully assessed and recorded. Residents are involved in the decisions affecting their lives as much as possible with staff support. EVIDENCE: Three residents files were looked at in detail. Information was good and provided staff with clear guidance on how specific care needs should be met. Each resident had an assessment that covered areas of risk linked to their condition, illness or behaviour. A list of likes and dislikes, wishes and goals had also been completed. Each care plan had been reviewed monthly, and there was a summary of events. This provides an overview of what has happened over recent months. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 11 Staff and where possible, residents had been involved in the care planning process. These are used as a working document and staff referred to them. Assessments and plans explained what help is required with personal care, social activities and daily living. Some residents are able to leave the home unaccompanied and others require staff to escort them around the wider community. Any limitations that are imposed have been formally assessed and care plans to manage risk have been completed. Confidentiality is taken seriously among the staff team and recent training had been provided to make sure staff were working with within the policy. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to take part in fulfilling, purposeful and meaningful activities, which meet their expectations. EVIDENCE: Staff keep a daily record about each resident. This shows what the resident has been doing and what progress has been made. Staff said residents get a lot of opportunities to go to the local and wider community, including places of worship, temples and shops. Management and staff monitor the quality of the activates available and use their local knowledge to enhance the type of recreation provided. It was also Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 13 clear that if residents wanted to spend time alone and not be involved in activities this was also respected. The residents said they enjoyed the food provided. The cook is able to produce a wide range of traditional English and Indian dishes. A snack meal is provided during the day for those residents not attending day services. The main meal of the day is served at teatime. Staff support residents to be as independent as possible. This includes residents taking responsibility for some food and drink preparation and cooking. The involvement of staff is determined by the individual skills and abilities of each resident. The home provides a small kitchen area in the dining room where residents can make themselves drinks and snacks. However, the main kitchen is used to provide the majority of meals. At the last visit, one resident was leaving the home regularly and due to the risk this posed to his well-being staff had involved the police and social worker. A review was held and staff continue to work with the resident to promote his best interests. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to make sure healthcare needs are met. Staff are not keeping medical records up to date. EVIDENCE: There are systems in place to make sure residents have access to services involving their health care. District nurses provide treatment and care as needed and are informed in advance if a resident moves in and needs to continue having visits. Staff work with local doctors surgeries and residents are registered with the local practice if they move in to the home from out of the area. Staff consult with healthcare specialists for advice and guidance. For example, about the correct use of aids and adaptations or medication reviews. Relevant details were recorded and added to care plans if appropriate. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 15 Storage of medication is good. There is a locked store cupboard where the drugs trolley is kept. Staff who are responsible for administering medication have completed medication training. A risk assessment is completed for each resident who wishes to look after their own medication. The medication record was not accurate. Medication had been given but the member of staff doing this had not signed the record and a space had been left. Staff attend appointments with residents if necessary. However, the home’s policy on this reinforces the importance of treating residents with respect and dignity. On the day of the inspection a member of staff accompanied a resident on a medical appointment. This was normal practice. The manager also confirmed that when residents needed an escort for appointments, additional staff were added to the rota to cover this and a taxi ordered if required. To help residents to maintain their independence and quality of life the home has a key worker system. This is where each resident has a designated member of staff, who oversees their care, and is usually from the same cultural, religious background or the same gender. Residents, who were able to share their views, said they felt well supported by their key worker and had a good relationship with them. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The level of staff understanding gives assurance that complaints will be taken seriously and service users will be protected from abuse. EVIDENCE: There had been no complaints over the last six months. One incident had been referred to the adult protection unit in 2005 and reported to the Commission for Social Care Inspection (CSCI). This is because there had not been any serious incidents, rather than there being a lack of understanding when incidents should be reported. Staff have been working with other professionals, including CSCI to make sure the resident is safe. The complaints procedure was displayed in the entrance hall for visitors and residents to see. Staff spoken to said they had not received training on adult protection. Copies of the adult protection procedures are kept in the manager’s office, and available for staff to read. However, staff showed a good awareness of what they should do if they thought residents might have been subject to any form of abuse and were able to identify the different types of abuse possible. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 17 Financial records were looked at. At the last inspection this was not being managed correctly. The manager does not deal with this directly, other than overseeing petty cash and other small amounts of money. Therefore the owners need to provide written evidence of what steps have been taken to make sure residents money is being handled in a transparent and auditable way. Those residents needing assistance are helped and if possible staff identify this as a skill, which may need to be developed, for example budgeting, and identification of money and its value. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The design and layout of the home allows residents to live in a safe and comfortable place. Although some areas would benefit from selective redecoration and refurbishment to create a more homely feel. EVIDENCE: The home meets the needs of residents. However, if the needs of residents change and they are unable to manage stairs then they may not be able to continue to live at Walmer Lodge. Wallpaper and paintwork is showing signs of wear and tear and needs refreshing. The area used by residents to make drinks and snacks still lacks invitation and the room seemed dark in comparison to the main sitting room. The pipes under the sink in one resident’s bedroom were leaking. The inspector did not see written evidence that the hard wiring in the home had been checked by a certified person. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 19 The home was clean and tidy. Staff explained the difficulties residents had if their mobility deteriorates. This had occurred and staff were able to move the resident to a lower floor to stop them having to climb more than one flight of stairs. The resident said they thought this was a better bedroom. There is a call system, which residents can use to summon help from staff. Staff said the system worked well if residents understood how to work it. Otherwise checks were made of residents, when they were in their room. Resident’s bedrooms reflect their choices and personalities. They varied in style and some have ensuite facilities. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected and supported by the staff recruitment procedure. However, staff still need to be trained so that they can do their jobs well. EVIDENCE: The recruitment files of three members of staff were reviewed. The files included a completed application form, two written references and interview notes. All staff have a criminal records bureau check. Staff have been supported to pursue external qualifications including National Vocational courses. However, it was not possible to assess the level of training provided or planned. The manager agreed to provide written information about this. The staff team covers a range of diversity and reflects the cultural and gender of residents at the home. Staff confirmed they were receiving supervision on a one-to-one basis as required. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is satisfactory. However, the owners need to provide evidence that resident’s finances are being correctly managed and they are protected from abuse. EVIDENCE: The manager has relevant experience and qualifications to be able to run the home in a competent and effective manner. But the owners need to provide written evidence to show they have systems in place to make sure residents money is dealt with properly. The staff team put residents needs first and take pride in the work they do. Staff and residents talked about the manager in a positive way and described Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 22 his management approach and manner as firm, but open and friendly. They said he would work with them to make sure residents were being cared for properly. Rapport between residents and staff was friendly and appropriate. There was an element of banter, however, this was felt to be in accordance with the wishes of residents taking part, who later said they enjoyed the relationships they had with staff and felt included in the atmosphere of the home. The home has a health and safety policy which staff were familiar with. Fire alarms and emergency lighting are tested weekly and routine fire drills were being carried out. The inspector was told there were daily handovers between the morning, afternoon and night staff. She sat in on two of these. The time was used to discuss each resident’s wellbeing and whereabouts and what the following shift was to cover. All staff had some input. There had been two staff meetings since November 2006. The minutes showed a wide range of agenda items had been discussed. Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 17(1)(a) Schedule 3 3(i) 16 & 23 Requirement The registered provider must make sure medication records reflect the medication being given to residents. The registered provider must make sure that the home is homely, decorated and carpeted to a suitable standard. And that routine maintenance is carried out. Written evidence is needed to show that the electrical hard wiring is safe. The registered provider must make sure staff are suitably trained and provide the CSCI with a list of training provided and planned. The registered provider must make sure that resident’s finances are dealt with properly and that they are protected from abuse. A written account of how this is done must be provided. Timescale for action 04/05/07 2 YA24 27/05/07 3 YA35 18 27/05/07 4 YA42 13(6) and 26 04/05/07 Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Walmer Lodge DS0000001222.V330692.R01.S.doc Version 5.2 Page 27 - 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!