Inspection on 28/10/05 for West Lodge Care Home

This inspection was carried out on 28th October 2005.

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 25/01/06

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 28th October 2005 04:09 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.V262594.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.V262594.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.V262594.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 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.V262594.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 28th October 2005 over a 5 hour period and time was spent talking to service users, staff, visitors and management, looking at records and the building itself. The home had recently engaged a new manager who was developing her skills and gaining experience of the role. Service users comments were generally positive about life at the home and about the staff and manager. It was evident that a good rapport had developed between the staff and service users and that life at the home met with service users expectations. What the service does well: What has improved since the last inspection? Since the last inspection the new manager has developed into the role and has maintained a good rapport with service users and visitors and is progressing towards the achievement of NVQ 4 in management. West Lodge Care Home DS0000000772.V262594.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.V262594.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.V262594.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): 1, 2 and 3 The home provides satisfactory information to service users and carries out a full assessment prior to moving into the home. EVIDENCE: In discussion, service users and their relatives said they had been given information about the home before making the decision to live there, although they were aware of the reputation the home had built up for providing a good standard of care. A separate Statement of Purpose was not available for inspection but the home’s Service User Guide contained relevant details and a summary of what could be expected to be found within a Statement of Purpose. It was advised that a separate document be developed and the Service Users Guide is made available in a more service user friendly format. It was noted that service users files contained a contract or terms and conditions between the home and the service user and that these had been signed to show agreement. West Lodge Care Home DS0000000772.V262594.R01.S.doc Version 5.0 Page 9 The manager was able to show the assessment procedure carried out before the service user moved to the home and the how further assessments were conducted to ensure that the home continued to meet the service users assessed needs. West Lodge Care Home DS0000000772.V262594.R01.S.doc Version 5.0 Page 10 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): 7, 8 and 10 Care planning is carried out to ensure service users needs are met and care is provided in a respectful manner. EVIDENCE: Individual service user care plans contained satisfactory information to enable staff to meet the assessed needs of the service users. The plans were detailed and the manager said monthly evaluation of care was carried out and the care plans updated accordingly. In discussion, service users and their families were very complimentary about the care received by their relatives and one service user said he “wouldn’t want to live anywhere else”. Another service user said the staff were helping her to maintain her mobility and was pleased to be able to keep her independence in this way. Relatives said they were welcomed at anytime to visit the home and service users said they were treated with respect and always in a dignified manner when receiving personal care. West Lodge Care Home DS0000000772.V262594.R01.S.doc Version 5.0 Page 11 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): 12 and 13 The home provides a satisfactory range of activities, meeting service users needs. EVIDENCE: A range of activity is available at the home including Bingo and visits by entertainers. An activity co-ordinator is employed at the home and engages service users in joining in the many activities on offer that include trips to the theatre and local areas of interest. A service user said that he joined in with the activities when he wanted to, but preferred his own company and watching television. The service user said he would like to have Sky TV installed in his room and was going to ask the manager to find out if this was possible. In conversation with service users and relatives it was found that visitors to the home were encouraged to visit their relatives at any time. One visitor to the home said the home was “very clean and the staff are very nice” and she could always meet with her relative in private. West Lodge Care Home DS0000000772.V262594.R01.S.doc Version 5.0 Page 12 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): 16 and 18 The home has a satisfactory complaints system in place. Information, relating to the protection of vulnerable adults, in use at the home needs updating. EVIDENCE: A complaints policy and procedure is in place at the home and made available to service users and their representatives. In discussion, service users confirmed they felt safe at the home and knew how to make a complaint. A service user said, “If I had a complaint it would be treated seriously”. The home operates an Adult Protection policy and has developed a booklet based on the policy for staff use. It was advised that this policy is linked to the Local Authority Protection of Vulnerable Adults strategy “No Secrets” and that this procedure should be followed in the event of an incident of abuse occurring at the home. West Lodge Care Home DS0000000772.V262594.R01.S.doc Version 5.0 Page 13 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): 19 and 26 The home is well maintained, clean and hygienic. EVIDENCE: Observation of the home found it to be generally well maintained and pleasantly decorated. Communal areas were well used by service users and appropriately furnished. The garden areas were pleasant and there was an area set aside for growing vegetables for use in the home. The manager said that since the last inspection some new carpets have been provided. The home was clean, tidy and free from odour. Visitors to the home said that the home was “always very clean”. West Lodge Care Home DS0000000772.V262594.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): 29 The home operates a robust recruitment and selection policy. EVIDENCE: Recruitment to the home was carried out following the homes recruitment policy and 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 at the home were long standing employees and were willing to enhance their roles through training courses. The manager said there had been no recent applications for employment made to the home as the staff team is very constant with little turnover and a bank of staff is also available to cover shortterm vacancies. West Lodge Care Home DS0000000772.V262594.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): 31 and 35 The home is well managed and robust procedures for the safekeeping of service users money are in place. EVIDENCE: The registered manager has been in post at the home only recently but has worked at the home for a number of years. Since taking up the position of manager, she has gained good experience within the role. Currently, the manager is studying for NVQ4 management and is a qualified 1st level nurse. The manager was able to demonstrate her capabilities to carry out her duties with confidence and maintain a good rapport with service users, staff and visitors. In discussion, a relative commented that the manager always kept her informed about issues of their relatives care, and had a good attitude. Examination of service users personal allowance records found them to be accurately maintained, but would benefit from and evidence of regular review and audit. West Lodge Care Home DS0000000772.V262594.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 2 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X West Lodge Care Home DS0000000772.V262594.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. 1 Standard OP1 Regulation 4 Requirement The registered provider must compile a Statement of Purpose as detailed in the Care Homes Regulations 2001 The Registered Person must ensure that the homes policy on Abuse reflects the current Local Authority arrangements under No Secrets. Timescale for action 31/12/05 2 OP18 13 31/12/05 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 OP1 OP35 Good Practice Recommendations The manager should develop the Service User Guide in a more easily readable format. The manager should provide evidence of audit and review of service users personal finance records. West Lodge Care Home DS0000000772.V262594.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.V262594.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. 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