Inspection on 20/09/06 for Walmer Lodge

This inspection was carried out on 20th September 2006.

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 7 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 20/03/07

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 20 September 2006 08.00a th Walmer Lodge DS0000001222.V302701.R02.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.V302701.R02.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.V302701.R02.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.V302701.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Walmer Lodge is a privately owned care home. It is situated in the Manningham area of Bradford, approximately one mile from the city centre. The home is well positioned for public transport. It is managed by Mr Tifin Shehu, who is registered with the Commission for Social Care Inspection. The home is registered to care for twelve service users with either mental health problems or learning difficulties in single bedroom accommodation. 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 service users with physical disabilities. There is a small garden to the front of the property, which allows parking for two vehicles. There is further car parking to the rear, however this is not used regularly as the access through is narrow. The current fee is £339.92 per week. This fee includes all toiletries, hairdressing, newspapers supplied by the home and chiropody treatment. This information was provided by the manager in June 2006. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area e.g. medication or food provision and are known as random inspections. The visit was unannounced and carried out by one inspector. The inspector arrived at 8.00am and feedback was given at the close of the visit at around 5pm. A pre-inspection questionnaire was sent out to the home prior to the visit. This was subsequently returned and provided information about the home; records and procedures; staff and residents. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at the completed preinspection questionnaire, the number of reported incidents and accidents, the action plan submitted 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 documents were looked at during the visit; some areas of the home were seen, such as bedrooms and communal areas. The inspector also spent time talking to residents and staff. Residents who were unable to comment on their experiences were observed. CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives or visitors. Views shared by the residents and relatives are contained throughout this report. There were ten residents living at Walmer Lodge on the day of the visit. There was one vacancy and one resident was in hospital. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 6 At the time of writing this report, five relatives and visitors and eight residents had returned their comment cards. One resident had completed their comment card independently, two others had had the assistance of an advocate or relative and five cards had been filled in by the residents’ key worker. Overall levels of satisfaction were good, one relative said the ‘quality and choice of meals are very poor’ and another felt the home should be ‘thoroughly monitored as staff don’t know how to do their job properly.’ Neither of the relatives or visitors gave their names or contact details so it was not possible to discuss their comments further. One resident, who said they did wish to speak to an inspector, did include their contact details but as yet the inspector has not been able to speak to them. What the service does well: What has improved since the last inspection? Since the last inspection one bedroom had been redecorated and a new carpet fitted. However, this bedroom is in need of additional redecoration since the wallpaper has been damaged. The communal toilets, bathrooms and hand washbasin in the laundry have had a thorough clean and are now included in the cleaning schedule. The roster now shows who is in charge of each shift. The home employs a domestic assistant, Monday to Friday, for three hours a day. On a weekend, care staff carry out general cleaning duties. The manager organises fire drills according to advice given by the fire safety officer. This is now recorded in the fire register. The inspector said that the Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 7 names of those taking part should be included to allow an audit to be carried out. Staff are still in the process of working towards their National Vocational Qualifications (NVQ) at levels 1, 2, 3 and 4. At present more than 50 of the care staff have this qualification. 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. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 8 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.V302701.R02.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. People who may use the service and their representatives have the information they need to choose a home, which will meet their needs. Residents are clear of what they can expect from the home as they are given a contract on admission. EVIDENCE: During discussions with residents they said they had received sufficient information before moving into Walmer Lodge to help them make up their minds about moving in. Two residents said they were encouraged to move in and give it a try due to them not being able to cope in any other setting. They said they were glad they came and had decided to stay. The manager confirmed that the statement of purpose being used was up to date and had not changed since the last inspection. It is recommended that more be done to make the information more accessible to residents who may have limited reading skills and understanding. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 10 Evidence was seen to show that residents have a needs assessment before coming to live at Walmer Lodge and any additional information provided by other parties, e.g. Social Services, is considered before residents are invited for a visit and trial stay. All of the current residents are funded through a local authority and their admission is based on a three-month trial stay before a review is held to confirm Walmer Lodge is suitable. All but two of the eight comment cards returned by residents confirmed that they had sufficient information about the home and had a choice about moving in. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. Residents are involved, within their capabilities, in decision-making about their lives and play an active role in the planning, care and support they receive. Some improvements are needed to make sure care plans accurately reflect the care required and risk assessments need to be more specific to make sure needs are met. EVIDENCE: The principles laid down by the manager and maintained throughout the staff team are the rights of all the residents to be treated as individuals and to enable them to take control of their lives. Staff talked to the inspector about how they were able to promote the wishes of residents and gave examples of where decisions had been made by Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 12 residents with their support. It was also clear from how the staff talked about the residents in their care, that they knew their limitations within the care home and that they worked within those boundaries. One resident in particular had challenged the boundaries of the home to maintain an acceptable level of safety and staff were in the process of reassessing this resident in a controlled and systematic way. All options had been put to the resident, their family and social worker. An urgent review had been organised so that all those involved could agree what could be done to satisfy the resident. The majority of residents said they did have control over decisions, if they wanted to. Two residents said that decisions were not always to their liking but they understood that their alternative choice was unrealistic and the outcome would not be good. Since the last inspection two residents have moved out of Walmer Lodge. One resident is now living in his own flat in the community and another resident has moved back to live with his family. Residents are helped to manage their own financial affairs. Staff support residents as required. It was evident that large cash amounts are being kept in the home safe. This must be addressed as a matter of urgency with the relevant third party involvement where required. Residents said they knew who their nominated worker was. Senior staff have the role of key worker and care staff provide support around the agreed areas of care. There was written evidence on care plans showing what staff were doing to meet residents needs and any changes in the care delivered. However, there were also examples given verbally about the care needs of residents and this had not been included in their care plan. One resident said he was aware a file was kept which included his details but did not wish to read it that often. He said he had signed his care plan over recent months and did so every so often to agree with the content. He said he thought the information was true and matched what he thought he needed to stay well. Risk assessments are in place, but can be improved. Some risk management is reactive rather than planned. The focus being to keep every one involved safe, rather than there being a review of residents needs and a structured plan being put in place. For example, one resident showed behaviours of aggression and violence and another resident had specific needs around engaging with staff, however, there were no procedures or guidelines in place to show how these had to be managed or what action was to be taken to minimise any risk to the resident or others around them. All incidents in the home are recorded in full and statements are taken from any staff involved. The manager monitors the number of incidents and discussed these during supervisions and handovers with staff. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 13 Practices in the home are supported by company policies and procedures. Staff meetings are held, but these are not very frequent. The last two being held in May and July this year. Residents’ meetings are also infrequent. But those residents, who had a view, said they did not think these needed to be any more frequent as not many people contributed and if residents needed to bring anything up it was easy enough when everyone was at home. This is therefore highlighted as a recommendation. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. 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 the home. Residents living at Walmer Lodge are able to make choices about their lifestyles. Staff help them develop life skills. Social, educational, cultural and recreational activities meet residents’ expectations and residents maintain strong links with their family and friends. EVIDENCE: Residents said they are able to take part in a range of activities, which suit them. These were age, peer and culturally appropriate. Where needed, staff accompany residents to outside placements. Residents do make good use of the local community. Staff support residents to be as independent as possible. This includes residents taking responsibility for simple food and drink preparation and Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 15 cooking. The involvement of staff is determined by the individual skills and abilities of each resident. Residents were not seen eating their meals but they told the inspector that food was good, well prepared and plentiful and that they had enough time to finish their meals. They said meal times were flexible, apart from the main evening meal. Staff provide support and guidance to residents about the benefits of healthy eating. One relatives’ comment card said the quality and choice of meals was very poor and one resident said that the menu was sometimes repetitive. A snack meal had been provided during lunchtime and one resident said she had had an alternative dish, as she did not like the one provided. A freshly prepared dish is served at teatime, this being the main meal of the day with a dessert to follow. The home employs a full time cook. Food provision appears well planned and the menu choices do reflect the choices of residents. The menus are organised to include both halal and nonhalal meals. 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 bulk of food. Residents discussed the relationships they had with family and friends. They said they were supported to maintain links with others and helped to identify people that made them happy and those who might be detrimental to their welfare. Some residents spend time away from the home with family. These visits are planned and felt to be in the resident’s best interests. One resident is leaving the home regularly and due to the risk this poses to his well-being staff have involved the police and social worker. As mentioned else where in this report an urgent review has been organised to discuss the best care for this resident. Residents are provided with a key to their rooms; however, they do not have a front door key for security reasons. Residents were seen to come and go as they pleased throughout the visit. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The health and personal care provided at Walmer Lodge is based on individual needs and carried out in a way, which gives residents privacy. Residents are treated with dignity and staff respect their cultural and religious beliefs. EVIDENCE: Residents have access to a wide range of health care service, over and above routine appointments with their doctor. Residents are able to choose which doctor they want in the local area and are registered with opticians, chiropodists and dentists where necessary. Evidence was seen on resident’s files that appointments are made for them to attend clinics and dental appointments but residents have refused to attend. Staff have continued in their efforts to make sure residents receive proper attention, however, they are limited when residents decided not to go. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 17 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 had come into work to accompany a resident on a medical appointment. This was said, by two residents, to be normal practice. The manager also confirmed that when residents needed an escort for appointments, additional staff were put on the rota to cover this. Medication records were checked and were being completed properly. Storage arrangements are good. Medication is delivered in a monitored dosage system. Residents who have the capacity are encouraged to keep and take their own medication. At the time of this visit, two residents were self-medicating. One resident explained how this worked and said he preferred to take charge of his own tablets. Both residents have suitable storage facilities in their bedrooms. Only staff trained to do so give out and record medication. The chemist who supplies the home provides training for staff and undertakes audits on a regular basis. Residents said that the daily routines in the home were flexible and that they could decide for themselves when to go to bed/get up, go out or have a bath. Those residents needing support appeared to have the same choices. However, it is acknowledged that if transport is booked for residents to attend arranged activities, for example day services, then there is some structure built into their day, which allows them ample time to wash, dress and eat before they leave. To support residents in maintaining their independence and quality of life the home operates 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.V302701.R02.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. Residents can be sure any concerns, complaints or allegations will be dealt with appropriately as they have access to a complaints procedure and are able to raise concerns and staff have sufficient knowledge to protect residents from abuse and harm. Residents’ finances are not fully safeguarded. EVIDENCE: The home has a complaints procedure, which all but one resident, said they understood and knew how to make a complaint. The policies and procedures around the protection of residents are satisfactory. The policy makes it clear when incidents need input from other professionals such as community nurses or psychologists and who staff should contact. One adult protection issue had occurred over recent weeks and was being dealt with in accordance with the home’s policy. In discussion, staff demonstrated an awareness of the content of the policy and knew to report any suspicions to a senior member of staff. On the whole, residents said they felt safe and supported. Two residents discussed their feelings about how staff made sure they were safe and agreed with the way this was being done. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 19 There had been no complaints in the last twelve months. Comment cards suggested that two relatives had made complaints in the past but these were made directly to the home and had been resolved. The registered providers deal with the financial arrangements and it came to light during the visit that the home currently holds a significant amount of cash belonging to residents. Arrangements must be made, as a matter of urgency, to safeguard resident’s money and if necessary independent advocacy or third parties must be involved to ensure this is done properly. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. The design and layout of the home allows residents to live in a safe and comfortable place. Although some areas would benefit from replacement floor covering and a more homely feel. Some maintenance requirements were also highlighted. EVIDENCE: The home provides a physical environment that meets the needs of residents. However, the floor covering in the dining room is in need of replacement – it is showing signs of heavy wear and tear. The area used by residents to make drinks and snacks lacked invitation and the room seemed dark in comparison to the main sitting room. Residents can personalise their rooms. Residents showed the inspector around their own bedrooms. Not all bedrooms were seen as the occupants were either out, busy elsewhere or not willing to give access. However, all communal Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 21 areas were seen. The smoke room is separate from the main lounge and residents also have access to a quiet room, which doubles up as the staff sleep in room during the night. Concrete steps lead up to the front door and the home does not have a passenger lift, therefore residents need to be able to climb stairs. All the residents manage this at present, although staff are aware of the need to monitor residents’ abilities to make sure this remains a suitable environment for them. Bedrooms are on the first and second floor; living space, the laundry and managers office is on the ground floor. Standards of cleanliness had improved since the last inspection. Two bedrooms had been recarpeted and redecorated, along with the smoke room and ground floor toilet. As a result of this visit the following work is required: • • • • • • The extractor fans in the main kitchen need to be thoroughly cleaned and added to the cleaning schedule. Windows, which are overlooked, must be provided with some form of curtaining or covering to make sure residents are given privacy particularly during the evening and night. Adequate ventilation needs to be provided in the designated staff toilet so that this facility can be brought back into use. Staff must have access to suitable crockery and cooking equipment. Including pans, dishes and if necessary a steamer. The floor covering in the dining room must be replaced. Ideas of how the home can look and feel more homely should be explored with staff and residents and their visitors. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. 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 the home. Residents are protected and supported by the staff recruitment procedure. However, the manager was not aware that CRB (Criminal Bureau Checks) were not transferable. Resident’s needs are met by staffing arrangements at the home, however to make sure this continues they must be trained further. EVIDENCE: The manager confirmed that they have one care assistant vacancy. The shortfall in hours was being covered using an agency worker. The rota provides for a senior member of staff on each shift, including night duty. The recruitment files of three members of staff were reviewed, including a new starter. The files included a completed application form, two written references and interview notes. All staff had a criminal records bureau check. However, one member of staff had brought a check, which had been done at a Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 23 previous care home. The manager was not aware that the checks have to be done with all new employees. He agreed to deal with this immediately. Staff have been supported to pursue external qualifications including NVQ’s. The kitchen staff have not been provided with food hygiene training. It is strongly suggested that the manager review all of the staff training to make sure staff have been provided with the minimum training requirements to allow them to complete their roles competently. 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.V302701.R02.S.doc Version 5.2 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43 Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to the home. The management and administration of the home is satisfactory, apart from there being no formal arrangement for the registered provider to report on the conduct of the home or safeguard resident’s finances. EVIDENCE: The manager has relevant experience and qualifications to be able to run the home in a competent and effective manner. However, the registered provider does not carry out his obligations with regard to monthly visits to report on the conduct of the home, or to safe guard resident’s finances. As stated in the section concerning residents’ protection, the registered provider deals with the financial arrangements and it came to light during the Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 25 visit that the home currently holds a significant amount of cash belonging to residents. Arrangements must be made, as a matter of urgency, to safeguard resident’s money and if necessary independent advocacy or third parties must be involved to ensure this is done properly. The staff team is resident focused and works well with other agencies and professionals. Staff referred to the manager in positive terms and described his management approach and manner as open and friendly. They said he would work with them to make sure residents were being cared for properly. Residents said staff were friendly and one resident said the manager was ‘bossy’, but that he needed to be sometimes to keep the staff working well. One comment card, from a visitor said the staff didn’t do their job properly and that Walmer Lodge needed to be thoroughly monitored. From observations and discussions with staff and residents the inspector did not gain the view that the staff were not able to carry out their duties. Rapport between residents and staff was noted to be 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. The last fire drill was carried out within the last six months, however, the names of those taking part needs to be added to allow for an audit to be made. The inspector was told there were daily handovers between the morning, afternoon and night staff. She sat in on one 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. Staff meetings are not held that frequently. This is highlighted as a recommendation. Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 26 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 3 2 3 3 3 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 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 3 X 3 X 3 X X 3 1 Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 15(2)(b) and (c) Requirement The registered provider must make sure that the care plans are kept up to date and reflect the current care needs of each of the residents. The registered provider must make sure that risk assessments are in place for all residents. The registered provider must make sure that resident’s finances are dealt with properly and that they are protected from abuse and that a report is provided about the conduct of the home. The registered provider must take the action required to address the requirements involving the premises and facilities. a) The extractor fans in the main kitchen need to be thoroughly cleaned and added to the cleaning schedule. b) Windows, which are overlooked, must be provided with some form of curtaining or covering to make sure residents are given privacy particularly Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 28 Timescale for action 03/11/06 2. 3. YA9 YA23 13(4) 13(6) and 26 03/11/06 03/11/06 4. YA24 16 and 23 03/01/07 5. YA34 19 6. YA35 18 7. YA43 13(6) during the evening and night. c) Adequate ventilation must be provided in the designated staff toilet so that this facility can be brought back into use. d) Staff must have access to suitable crockery and cooking equipment. Including pans, dishes and if necessary a steamer. e) The floor covering in the dining room must be replaced. Ideas of how the home can look and feel more homely should be explored with staff and residents and their visitors. The registered provider must make sure that the necessary checks are carried out before staff start work at the home. The registered provider must make sure that staff have access to training, which will allow them to carry out their duties competently. The registered provider must take the necessary steps to safeguard the finances of residents who are not able to look after their own affairs. 03/11/06 03/01/07 03/11/06 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 2 Refer to Standard YA1 YA7 Good Practice Recommendations It is recommended that more be done to make the information more accessible to residents who may have limited reading skills and understanding. It is recommended that the manager review the frequency of staff meetings to make sure enough is being done to share information. This also applies to residents meetings. DS0000001222.V302701.R02.S.doc Version 5.2 Page 29 Walmer Lodge Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Walmer Lodge DS0000001222.V302701.R02.S.doc Version 5.2 Page 30 - 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!