CARE HOME ADULTS 18-65
West Lodge 39 Frederick Gardens Penshaw Houghton-le-spring Tyne And Wear DH4 7JY Lead Inspector
Mrs Elsie Allnutt Announced Inspection 17th October 2005 10:00 West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 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 West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 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. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service West Lodge Address 39 Frederick Gardens Penshaw Houghton-le-spring Tyne And Wear DH4 7JY 0191 385 7169 0191 385 7169 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) Community Integrated Care Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (3), Mental disorder, excluding of places learning disability or dementia (1), Physical disability (2) West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: West Lodge is a detached two-storey building, which was originally a private house. It is situated in a quiet location at the end of a cul de sac amongst a variety of private houses in Penshaw. Some structural alterations were undertaken prior to the home’s registration but it retains its domestic appearance in many ways. There is a spacious drive sufficient to park four vehicles and local amenities such as a post office, corner shops, and pubs within a few minutes walking distance in Penshaw. The building provides six individual bedrooms, two of which are on the ground floor and four on the first.There is a large lounge/dining room, kitchen and laundry room all shared by the service users as well as accessible well stocked gardens. The home is registered to offer a service to 6 people with a learning disability, including 2 who may have physical disabilities and 2 over the age of 65years. A variation was made to the registration to accommodate a service user with learning disabilities and additional mental health needs. This variation applies specifically for this person. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 4 hours over one day in October 2005. Questionnaires were sent out to service users and their relatives prior to the inspection, all were returned from service users and three were returned from relatives. The manager supported the service users to complete the questionnaires using her knowledge of their communication methods. All service users and two relatives indicated that they were satisfied with the service delivered. One relative indicated that in their opinion; there was not always enough staff on duty; that they were not aware of the homes Complaints Procedure; and that they were not satisfied with the overall care provided. On the day of the inspection a discussion took place with another relative of the same family and concerns regarding the dissatisfaction of the care provided were discussed. The relative stated that they were happy with the home generally and that there family member was living there. The particular issues that the family were dissatisfied with were discussed with the manager and case tracked in the care records. The views of the five service users and six members of staff were sought. As 4 of the service users do not have effective verbal communication their satisfaction of the service was interpreted through the observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were satisfied with the service and the care and support given by staff. A service user who had recently moved into the home and who is able to verbally communicate was able to give an explicit account of their life in the home that was positive. As part of the inspection process the service users’ care files and a sample of the homes records were examined and an inspection of the premises took place. What the service does well:
This service provides accommodation of a high standard. It is well maintained and as a result of effective cleaning routines offers a clean and hygienic environment. As found on the day of the inspection the friendly interaction of service users and staff create a warm and welcoming atmosphere in the home. A service user who had recently moved into the home confirmed that they were happy with their choice of home, they liked the people they were living with and they were well “looked after”. The manager explained that the aim of the home is to support service users to take an active role in leading the service. By observing life in the home the
West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 6 success of this approach was confirmed. Service users confirmed that in relation to the kind of activities organised they were supported to make choices determined by their personal preferences. The positive development of one service user, who was new to the home at a previous inspection, was demonstrated in the observation of their appearance and behaviour and the way they now interacted in a friendly way with other service users. The staff who are now well established have a good understanding of their roles and work well as a team, demonstrating enthusiasm and interest in their work. All, if not already qualified, are working towards the NVQ qualification. Each service user has a well-ordered care file making different sections easily accessible. They include well-written plans of care developed by individual service users and the member of staff with particular responsibility for their care, known as a “key worker.” If an activity presents any level of risk the plan of care is supported by a plan to reduce the level of risk for the people involved. What has improved since the last inspection? What they could do better:
To enable service users to be satisfactorily supported in their daily routines and chosen activity the staffing ratios should be reviewed in relation to the current needs of the service users. The manager should also be allocated sufficient hours where she can address solely the responsibilities related to her role. This will ensure that the home is run well and service users are kept safe. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 7 So that all service users and their relatives know and understand how to raise a concern or to make a complaint the manager should give them copies of the home’s Complaint Procedure document and explain verbally how to put it into practice. To complete the refurbishment of the home the laundry room is soon to be addressed. If any structural work is to be carried as part of the process the appropriate agencies must be informed, so that this is carried out safely and the health and safety of the service users is protected. 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. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 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 West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 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): 2 Service users needs are assessed prior to admission in order to determine that their needs can be met in the home. EVIDENCE: One new service user moved into the home earlier this year. Prior to their admission records showed that a pre admission assessment and care plan were received from the referring agency, in this case the social worker of the local authority. The assessment is comprehensive and includes important and relevant information about the service user and includes a list of their likes and dislikes, description of their behaviours and risks that are related to these, and areas where there are limitations of rights. The service user and records confirmed that the service user had visited the home prior to admission. The service user also confirmed that they had chosen to live at the home. Records of a six-week review confirmed that the home had stated that they were able to meet the service users needs. The homes care plan reflects the needs identified in the assessment and has risk assessments in place in relation to the risks identified, for example there are risk management plans with guidelines for staff to follow regarding challenging behaviour. The manager stated that the home had put these together with the assistance and guidance of the social worker. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 Detailed care plans and the staffs’ understanding regarding service users communication methods; enables service users to be supported to make decisions, which at times may include taking risks; and to direct their care in a way that they prefer. EVIDENCE: The changed care plan format that is illustrated with pictures and is now written with a person centred approach, increases the opportunity of service users accessing the information that is written about them. The care plan document was developed prior to the last inspection and all staff are now using it effectively as a result of receiving training. When reading through the care files it was evident that the care plans include appropriate detailed information, including risk assessments and clear risk management plans that include guidelines for staff to follow. Information in relation to the likes and dislikes of service users, the way they prefer to be assisted and the recording of observations of the response to
West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 11 activities experienced, assist staff to support service users in their decision making process. This ensures that service users are living a life in their preferred way and provides consistency in the delivery of the care and support given. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 16, 17 Service users rights to live a full and active lifestyle are respected and they are supported to have a regular community presence by accessing a range of community facilities, however the present staffing resources can limit the success of this. Service users are offered a choice of nutritious food that supports individual needs and a healthy lifestyle. EVIDENCE: By reading care plans and through observation it was evident that service users are supported to live active lifestyles. Individual care plans recorded activities service users enjoyed taking part in and demonstrated the structure to their week. One service user who has recently developed their independence now uses the Care Bus to access the facilities they chose to visit. Records and discussions with service users and staff confirmed the different community venues that service users visit, including the local leisure centre, theatre, local pubs and the bowling alley.
West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 13 A discussion took place with the manager in relation to two service users’ interest in swimming which lead into a discussion in relation to using special facilities at a local special school as opposed to using community-based facilities. Although the manager agreed that community inclusion is what should be aimed for, often to support service users in this way requires higher staffing numbers. A light lunch, that was tasty and nutritious, was taken at the home with two members of staff and one service user, as others were enjoying lunch out as part of their planned day. The manager stated that the menus have recently been reviewed with the intention of offering a more healthy choice of food. So that the special dietary needs of two service users are addressed a Dietician is involved in their care and monitors their nutrition intake. Records confirmed this. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users receive personal support appropriate to their needs and preferences, while also having their privacy and dignity promoted. EVIDENCE: The records in the care plans and the way they are written in a person centred approach, ensures that the preferences of the service users are addressed and that service users are supported to take the lead. For example one service user’s preference to the way they wished to be bathed was described in detail in the care plan and included steps to guide staff to support them in their preferred way into the bath, while also describing the lifting equipment involved and how it is to be used. The records showed that the dignity of the service user was a priority throughout the process. The observation of staff supporting service users with their personal tasks confirmed that they offered support discreetly and carried out the care task with care and skill. One service user, who was resting in the privacy of their room, confirmed that their personal needs were met with care and respect and in the way that they preferred.
West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 15 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 The home has a Complaints Procedure, that is also in picture format in an attempt to make it accessible to service users, that ensures that concerns and complaints will be taken seriously. However so that service users are fully protected and supported by people involved in their lives relatives/advocates must be made aware of them. EVIDENCE: The home has a Complaints Procedure that is also in picture format, a copy of which was found in the service users’ care files. With regard to the comment made in response to the relative’s comment card the manager is advised to send all service users’ relatives or advocates a copy of the homes Complaints Procedure. There have been no complaints recorded since the last inspection. However from discussions with staff and the manager there have been incidents in the home where people have demonstrated dissatisfaction through their behaviour. A discussion took place with the manager in relation to how service users might be supported to make their concerns known, emphasising that these should always be taken seriously, addressed and recorded. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 16 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): 24,28 The standard of the environment within this home is good providing service users with a clean, attractive, safe and homely place to live. EVIDENCE: The refurbishment of the home commenced prior to the last inspection and is now almost complete, resulting in an attractive and comfortable environment for service users to live. Advantage of using light coordinating colours for the decorating and furnishings has given a feeling of space and calmness. Service users and visitors were observed sitting in comfort in their surroundings. All service users have individual bedrooms that are decorated and furnished to reflect individual personalities. All have now been decorated and refurbished with individually chosen furniture. One service user proudly showed theirs and remarked, “I love it, it’s my room.” The manager discussed the plans that are in place to refurbish the laundry. As some building work is involved with the refurbishing process the manager was advised of the agencies to contact. It was also advised that the walls in the laundry area are finished with a washable surface.
West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 17 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): 33,34,35 Robust recruitment & selection procedures and regular training opportunities ensure that service users are appropriately supported and protected by a competent and qualified staff team, however there are not always enough staff to support individual service users activity requests. EVIDENCE: This home is now fully staffed and on the day of the inspection there were enough staff to adequately address the needs of the service users, this included the manager and 3 support workers. However the staff rota demonstrates that there is a minimum of 3 staff on duty and this usually includes the manager. Staff and the manager confirmed that 3 staff often seems an inadequate number to address the needs of the service users and to support them satisfactorily especially in their chosen activity. This was also recorded as the opinion of a service user’s relative on a pre-inspection comment card. Considering the current diversity of need amongst the service users the manager is advised to review the current staffing ratio in relation to the present needs of the service users. Staff were observed working with interest and discussed their training schedules with enthusiasm. The manager and records confirmed that all staff
West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 18 are either qualified in, or are working towards NVQ. Staff confirmed that they had attended training relevant to their role which included moving and handling, first aid, administration of medication and infection control. The manager and records confirmed that the home continues to follow the Company’s recruitment procedures which includes receiving 2 references and a clear CRB. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 19 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 A well-managed staff team promotes the health and safety of the service users, however, quality monitoring systems including systems for obtaining the views of the service users and their relative’s on the quality of the service provided, need to improve and to be formalised, so that the best quality of care for service users is maintained. EVIDENCE: The manager who is qualified and well experienced in her role is currently going through the registration process to be Registered Manager for this home. The manager was observed interacting with staff and service users in a positive way. Records showed that the manager is often included on the staff rota as one of the 3 staff on duty. As a result of this, little time is allocated to address her managerial duties. So that the manager can fulfil her full responsibilities without the care needs of the service users being jeopardized, West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 20 care hours must be allocated accordingly. This was a Requirement of the last report and will remain a Requirement of this report. Although the home has quality monitoring systems in place these are recorded in different places. It was suggested to the manager that the quality monitoring of systems might be more effective and easier to access, if they are kept in one file that was referred to as the Quality Assurance File. Staff were aware of health and safety issues and carried out their roles accordingly. The fire log and accident book were examined and were satisfactory. West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X 3 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
West Lodge Score 3 X X X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 3 X DS0000015758.V253333.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA28 Regulation 23(4)(5) Requirement If building work is involved with the refurbishing process of the laundry the relevant agencies for example, Environmental Health, The Fire Service and CSCI must be informed. Timescale for action 30/12/05 2 YA33 3 YA37 18(1)(a)(b) The manager must review the 30/11/05 staffing ratio to ensure that there are enough staff to address the current service users’ needs. 10 So that the manager can 30/11/05 address her full responsibilities as manager of home without the care needs of the service users being jeopardized care hours must be allocated accordingly.(Previous timescale of 30.06.05 not met.) West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 23 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 YA22 Good Practice Recommendations So that service users are fully protected and supported by people involved in their lives, relatives/advocates should be made aware of the home’s Complaints Procedure. It is recommended that as part of the refurbishing process the walls in the laundry area are designed to be washable. It is recommended that the quality monitoring systems are brought together as one Quality Assurance System to ensure that the service is monitored and developed in relation to the views of the service users. 2 3 YA28 YA39 West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 West Lodge DS0000015758.V253333.R01.S.doc Version 5.0 Page 25 - 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!
