CARE HOME ADULTS 18-65
West Lodge 39 Frederick Gardens Penshaw Houghton le Spring DH4 7JY Lead Inspector
Elsie Allnutt Unannounced Tuesday, 24 May 2005 10:00
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service West Lodge Address 39 Frederick Gardens, Penshaw, Houghton le Spring, DH4 7JY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 385 7169 0191 385 7169 Community Integrated Care PC Care home only 6 Category(ies) of 6 x LD; 3 x LD(E); 2 x PD; 1 x MD registration, with number of places West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 24th November 2004 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. Recently a variation has been made to the registration to accommodate a service user with learning disabilities and additional mental health needs. This variation applies specifically for this person. At the time of the inspection there was one vacancy in the home. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 7 hours over one day in May 2005. The views of the five service users and six members of staff were sought. As all but one of the service users do not have 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. The service user with verbal communication was able to give an explicit account of their life in the home and a prospective service user who was visiting the home at the time of the inspection also gave their views of the home. As part of the inspection process the service users’ care files and a sample of the homes records were examined. 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 potential service user visiting at the time said “it’s nice I like it, there’s plenty of room and the people are nice.” 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 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. Although all are relatively new to the home, the staff know what they are expected to do and work well as a team, demonstrating enthusiasm and interest in their work. A student, working on a placement at the time of the inspection, commented how organised and well thought out everything was. Each service user has a well-ordered care file making different sections easily accessible. They include well written plans of care developed by individual
West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 6 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:
So that storage space is increased and the area is easier to keep clean, plans should be put in place to reorganise and decorate the laundry room. The lighting in the ground floor bathroom is poor and could be improved with better light fittings and a window that would allow natural light in yet at the same time protect the service users’ dignity. One service user who has special dietary needs should have a plan in place to reduce any risk involved in the feeding process. This was discussed with the manager who agreed to put it in place. The staffing number required each day to address the needs of the service users is currently maintained by including the manager. Time must be allocated so that the manager is able to address the responsibilities of her role, including the administrative duties, therefore should not be generally included in the required staffing numbers. It is the Company’s practice that all the staff recruitment records are first received and filed in the Company’s central office and only later transferred to the individual homes. When inspecting two of the staff’s files there were only one reference in place for each. A discussion how this system might be improved took place with the manager. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 7 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 B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 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 standard(s) 1,4,5 Service users are provided with the information needed to make an informed choice about where to live and given an opportunity to experience life in the home prior to moving in. So that they are aware of the homes Terms and Conditions and the costs incurred they are provided with detailed contracts. EVIDENCE: Clear information is available to prospective service users about the services and facilities on offer at West Lodge. Both the Statement of Purpose and Service User Guide have been developed to be accessible to the needs of the service users. Minor adjustments have recently been made to these documents to bring them up to date with recent changes. Individual contracts include the full cost of the service provided identifying who is responsible for payment. At the time of the inspection a prospective service user was making a third visit to the home and on this occasion they were staying for tea. Their behaviour demonstrated that they felt comfortable in the home and their comment was; “I like it here.” West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 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 standard(s) 6,9 There is a clear and consistent care planning system in place for each service user that is regularly reviewed. This system provides staff with up to date information they need to satisfactorily meet the service user’s needs. However not all areas of risk have been identified and this could have a detrimental effect on the care of service users. EVIDENCE: The care plan process was developed prior to the last inspection and all staff have now received training in how to use it effectively. When reading through care files it was evident that care plans are in place with appropriate detailed information, including risk assessments and clear risk management plans that include guidelines for staff to follow. This provides consistency in the delivery of care. However for one service user who relies on Percutaneous Endoscopic Gastrostomy care (PEG feeding), although there are specialist guidelines for staff to follow in relation to using the clinical process, there is no risk assessment related to this procedure. So that risks are effectively managed this must be addressed.
West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13,14,15 Although service users are currently supported to take part in age appropriate community based activities there is room for these to be further developed so that more variety is offered. The home continues to successfully support service users in maintaining family links. EVIDENCE: On the day of the inspection all of the service users were observed to be involved in various activities. These included staff supporting service users on a trip out to a coastal resort and a visit to local shops, while one service user chose to independently listen to music in their room. The home is currently reviewing service users’ individual activity programmes. This is seen as positive progression and a discussion took place with the manager who described plans to further develop individual activity programmes further by using local community facilities and the knowledge of the service users preferences. One service user whose programme has successfully been reviewed and developed discussed the variety of community-based activities they were now
West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 12 enjoying. Some of the activities involved included visiting rock concerts, going out for coffee and cake and visiting exhibitions. They also explained that due to improvements in their confidence they were able to access some of the activities independently by using the care bus. This information was confirmed in the care plan. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,20 Service users’ healthcare needs are well met and satisfactory systems are in place in relation to the administration of medication, ensuring that service users medication needs are met. . EVIDENCE: Staff support service users to address their individual healthcare needs by assisting them to visit local GPs and attend hospital appointments. The outcomes of such visits recorded in the care plans confirmed this. As a result of spending some time in hospital one service user was dependent for a short time on the use of a catheter. A member of staff explained that due to the close observations of the staff, which were recorded in the care plan, the District Nurse was supported to deliver appropriate care in relation to this. A letter recorded in the care file of another service user described how pleased the Consultant was with the progress of this service user, since moving into the home. At the time of the inspection all service users were experiencing good health. Staff were observed administrating medication satisfactorily and following the homes procedures. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 14 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 standard(s) 23 Arrangements are in place to help protect service users from abuse. EVIDENCE: Staff confirmed that they have received awareness training regarding abuse and adult protection, as well as training in relation to handling verbal and aggressive behaviour. Staff spoken to were able to appropriately describe what action to take in a situation where they witnessed abuse. Service users’ appearance demonstrated that they were well cared for and their positive behaviour, in the home and when interacting with staff and fellow residents, established their satisfaction with the service provided. The local authority’s adult protection procedure is available within the home, to guide staff on what to do and the people to contact. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 15 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 standard(s) 24,27,30 The standard of the environment is good, providing service users with an attractive and homely place to live. However to ensure that service users are not at risk the recommendations made at a recent Fire Department inspection must be addressed. EVIDENCE: Several areas of the home have been redecorated and refurbished since the last inspection. New furniture, carpets and small furnishings in the lounge and hallway areas now provide comfortable and homely facilities for service users to relax in, and the redecoration and new flooring in two of the service users rooms provides hygienic, comfortable personal space. The repairs needed in the bathroom and identified at the last inspection have now been addressed, however there were some fire safety issues identified during a recent Fire Department visit that must be complied with. An immediate requirement form was served in relation to these. The overall cleanliness and good hygiene standards of the home proved the effective use of cleaning products and procedures. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34 The home employs a competent and qualified staff complement via robust recruitment and selection processes, which means that service users are effectively supported and protected by staff. EVIDENCE: The examination of staff rotas confirmed that an adequate number of staff are on duty each day to address the needs of the service users. This includes three members of staff on duty during the day and one on sleep in duty at night. The examination of staff files provided evidence that good recruitment procedures are in place. However two files included only one reference for each of the staff. It was suggested by the manager that the second references must still be in the Company’s central office. A more effective process must be developed. Staff discussed the needs of the service users with respect and understanding. When observing staffs’ social interaction with service users, and the way they addressed service users’ needs, it was evident that positive relationships were developing between them. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 The employment of a permanent manager has provided leadership, guidance and direction to staff and safeguards the health, safety and welfare of the service users. However the manager does not have enough dedicated time allocated to effectively fulfil the role of manager. EVIDENCE: After having an unsettled period over the past 18 months there is now a permanent manager employed at the home. The person is experienced and has been a Registered Manager at another home within the Company. Staff made complimentary remarks about the new manager and discussed with enthusiasm the recent discussion the team had in relation to developing a “service user lead” service. This was illustrated on a chart developed by the manager during the staff meeting identifying the “Path” forward while also demonstrating how staff and service users would be involved in the outcome. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 18 Currently the manager is included as one of the rota’d staff to meet the needs of the service users. So that the manager can fulfil her full responsibilities without the care needs of the service users being jeopardized, care hours must be allocated accordingly. As a result of examining health and safety records it was found that the accident book used to record the accidents of service users is not compliant with the Data Protection Act. This was brought to the attention of the manager. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 19 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 3 x x x 3 Standard No 22 23
ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 x x 2 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 3 2 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
West Lodge Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 20 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 9 Regulation 13(4)(c ) Requirement A risk assessment and risk management plan must be put in place in relation to Percutaneous Endoscopic Gastrostomy care (PEG feeding). To ensure that service users are not at risk the recommendations made at a recent Fire Department inspection must be addressed. So that there is evidence of the homes recruitment procedures being consistent and protective of the service users, 2 references for each member of staff must be available for inspection. The manager must submit an application forms to the CSCI as part of the process to be considered as Registered Manager for this home. So that the manager can address her full responsibilities as manager of home without the care needs of the service users being jeopardized care hours must be allocated accordingly. The accident book used to record the accidents of service users must be compliant with the Data Protection Act 1998. Timescale for action 30.06.05 2. 24 & 42 23(4) Immediate 3. 34 19 30.06.05 4. 37 9 30.06.05 5. 37 & 33 30.06.05 6. 42 30.06.05 West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 21 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 14 27 Good Practice Recommendations It is recommended that the variety of activities offered are further developed as planned. Consideration should be given to the lighting in the ground floor bathroom that is poor and could be improved with better light fittings and a window that would allow natural light in yet at the same time protect the service users’ dignity. West Lodge B52 B02 S15758 West Lodge V220813 24 May 05 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Baltic House Port of Tyne South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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