Inspection on 25/01/06 for West Lodge Care Home

This inspection was carried out on 25th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

West Lodge Care Home 19/07/06

West Lodge Care Home 28/10/05

West Lodge Care Home 01/03/05

West Lodge Care Home 04/08/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE West Lodge Care Home Peases West Billy Row Crook Durham DL15 9SY Lead Inspector Stephen Willcock Unannounced Inspection 25th January 2006 11:00 X10015.doc Version 1.40 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 Care Home DS0000000772.V269547.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service West Lodge Care Home Address Peases West Billy Row Crook Durham DL15 9SY 01388 763650 01388 768368 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) West Lodge Care Homes Limited Andrea Judith Gilchrist Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Terminally ill (2) of places West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 Brief Description of the Service: West Lodge care home is registered with the Commission for Social Care Inspection for 30 places providing nursing and residential. The home is situated in a small residential thoroughfare within the County Durham village of Billy Row, approximately 1.5 miles north of Crook Town. The semi rural setting around the village green features the Post Office, general store, church and pub and is on a regular bus route to Crook, Bishop Auckland, Weardale, Darlington, Durham and Newcastle. West Lodge was originally a large stone built country house and has been extensively altered and extended to provide accommodation on the ground and first floor. The home offers single and double room accommodation and all bedrooms are equipped with nurse call alert, plug-in points for TV and telephone. Communal TVs are provided in every lounge, a hi-fi system in the main lounge and the piano and organ in the dining room/conservatory on the ground floor. A passenger lift provides access to the first floor, as does the central stairway. Throughout the home is well equipped, decorated and furnished to a very good standard whilst retaining a domestic, homely environment. The home is surrounded by attractive well cared for gardens with seating and good access. There is ample parking space for visitors. There is a friendly and welcoming atmosphere and good links are well established with the local community in which the home enjoys a well-deserved reputation for providing good care. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 25th January 2006 over a period of 4 hours. During the inspection time was spent talking to service users, relatives, staff and management. A number of records were looked at and the grounds and building itself were inspected. Discussions with service users and their relatives found a high degree of satisfaction with the care provided and the rapport that had developed between themselves and the staff. Comments made by relatives suggested that the communication between the manager and relatives was “extremely good” and that the staff are “always caring, patient, willing to listen” and demonstrated “excellent care practices”. Service users comments were also favourable. One service user said, “quality care, top class” and “the staff are very protective, I feel secure”. What the service does well: What has improved since the last inspection? The manager has worked well to meet the requirements and recommendations made at the last inspection. Staff especially in studies leading to NVQ qualifications has undertaken further training. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 6 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. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 and 6 The home offers the opportunity of trial visits and assessments to ensure the home is suitable. EVIDENCE: The Director said prospective service users were invited, with their relatives, to come to the home for a visit to see the facilities offered, before making the decision to live there permanently. The manager would also conduct an assessment using a pre admission checklist and provide information about the home and useful telephone contact numbers. The home did not provide an intermediate care facility. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Arrangements are in place should a service user wish to control their medication. EVIDENCE: Currently there are no service users staying at the home who have expressed the wish to control their own medication. The Director said if a service user wished to control their own medication, a risk assessment would be carried out to ensure their safety. A metal safe had been purchased to contain any medication required by the service user on completion of the risk assessment. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15 The home encourages service users to retain control over their lives and provides a good variety of satisfactory meals. EVIDENCE: Service users said they could make choices in their lives including when to get up and go to bed and added that there were always plenty of things to do if they wished. Service users said they had been encouraged to bring their own possessions to the home including furniture and to personalise their rooms to their own tastes. Service users agreed that the food served at the home was of good quality and was always offered with an alternative course and catered for special dietary needs. The Director said the menus were currently being updated and advice had been sought from a dietician. The home had recently been involved in the Focus on Food project and had carried out a survey of service users asking about the quality of food served. The Director said the results of the survey were very satisfactory. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The home promotes and protects the legal rights of service users. EVIDENCE: In discussion, the Director said that service users families were encouraged to conduct their relative’s legal affairs if necessary, including voting in local and general elections by using the postal voting system if required. An advocacy service was available to service users and had previously been used at the home. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 24 and 25 The home provides a safe, comfortable environment that is well maintained. EVIDENCE: The home offers spacious and homely lounges for service users to meet with each other and to entertain visits from relatives in private if desired. The gardens are spacious and provide a safe and tranquil area to use in the warmer days. Service users rooms were seen to be clean and tidy, and contained personal possessions and items from their own homes. Service users said they liked their accommodation and that they were nice and clean. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 13 The home is well established and was well maintained although in need of redecoration in parts. Checks on fire systems and bathing equipment were carried out annually by professional services and as part of the homes maintenance process. Safety records were well documented and up to date. Communal areas were well used and pleasant to sit in and enjoy socialising. It was noted that water temperature records showed that at times water temperatures fluctuated and were sometimes quite high. The manager should arrange for temperature regulator valves, where fitted, to be checked and to fit them where they are required. The Director said staff, prior to bathing, rigorously checked water temperatures. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 The home promotes and protects the safety of service users through training and recruitment and selection procedures. EVIDENCE: Staffing levels at the home remain constant and included six 1st level nurses. Recently the home recruited a nurse from overseas and the Director was able to outline the processes involved in offering employment. The home employed 22 care staff and dedicated kitchen and domestic staff. Examination of staff files found evidence of satisfactory checks being carried out prior to the commencement of employment including Criminal Records Bureau checks and Protection of Vulnerable Adults checks. Staff training was progressing well, with all but two of the care staff having achieved NVQ2 in care, and 6 care staff had progressed to level 3. The Director said two of the care staff had shown an interest in carrying on their studies to NVQ level 4. Specialised training courses had been undertaken including peg feeding, tissue viability and dementia care. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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 and 38 The home is run in the best interests of service users and health and safety issues are addressed. EVIDENCE: The home carried out an annual quality assurance survey in the form of an evaluation questionnaire, the results of which were displayed on the homes notice board. Meetings were also arranged for service users to give their views and opinions on the running of the home. The manager was able to demonstrate that as far as reasonably practicable the health, safety and welfare of service users, staff and visitors to the home were maintained. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X 3 X X X 3 3 X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action 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 OP25 Good Practice Recommendations The manager should arrange for water temperature regulator valves to be checked where needed. West Lodge Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Care Home DS0000000772.V269547.R01.S.doc Version 5.0 Page 19 - 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. 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