CARE HOMES FOR OLDER PEOPLE
West Lodge Care Home 238 Hucknall Road Sherwood Nottingham NG5 1FB Lead Inspector
Sharon Rosenfeld Unannounced Inspection 9th November 2005 1:15 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 DS0000026478.V264409.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 DS0000026478.V264409.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service West Lodge Care Home Address 238 Hucknall Road Sherwood Nottingham NG5 1FB 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) 0115 9606075 0115 9606075 Ms Razma Vanessa Alishan Ms Razma Vanessa Alishan Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (21), Physical disability (4), Terminally ill (2) of places West Lodge Care Home DS0000026478.V264409.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Within the total number of beds a maximum of 4 bed maybe used for the category PD Within the total number of beds a maximum of 2 bed maybe used for the category TI 13th July 2005 Date of last inspection Brief Description of the Service: West Lodge Care Home was established in 1987. It now provides nursing and personal care for 27 residents. Within this number, the registration allows admission for up to 4 people who have a Physical Disability and 2 people who are terminally ill. The home is privately owned by Ms Razma Vanessa Alishan. Located on a main road in Sherwood, it is on a main bus route into Nottingham city centre. The home consists of a large converted house, with a purpose built conservatory. There are 6 double bedrooms and 13 single rooms 4 of which have en-suite facilities. There is ramped access to the building and a passenger list serves all three floors. The homes grounds are mainly to the front of the building and are well maintained although there is open access to the road. West Lodge Care Home DS0000026478.V264409.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted during the afternoon of 9th November 2005. The owner/registered manager was not present at the time of the inspection. Some of the standards could not be fully assessed because the information was not available to enable the inspector to form a judgement. The main method of inspection used was called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. Four residents and three staff members were spoken with to obtain their views on the home. What the service does well: What has improved since the last inspection?
The staff were observed assisting residents to eat in a sensitive and discrete way. Three people confirmed they enjoyed their meals. All of the needs identified in the three care plans seen had a corresponding care plan, which were legible and reviewed on a monthly basis. The care plans seen also contained information about the way the person preferred to spend their leisure time. The temperature in the lounge was comfortable and one resident confirmed this was not adversely affected by the opening of the conservatory door. West Lodge Care Home DS0000026478.V264409.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 DS0000026478.V264409.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 DS0000026478.V264409.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, 4. The statement of purpose and service user guide was not available for inspection. Prospective residents are not assured that the home can meet their needs. The staff are well informed about residents care needs. EVIDENCE: The person in charge could not locate a copy of the statement of purpose and service user guide. Individual records are kept for each resident. The file of one new resident was seen. It did not contain written confirmation that the home could meet the person’s assessed needs. One resident provided significant information about his care needs. He was confident that these were being met by the home and was satisfied with the services provided. Two staff members were also spoken with about the specific care needs of two residents. They were both well informed about their responsibilities. West Lodge Care Home DS0000026478.V264409.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): 7, 9, 10 Progress has been made to ensure that residents’ dignity is protected. The residents care needs are generally well documented and met. The medication policy must be more robust to ensure people are afforded appropriate protection. EVIDENCE: Three care plans were seen. The majority of health, personal and social care needs are well documented. The records evidenced prompt consultation with the community dietician, however the care plan had not been updated with the advice given. A description of the pressure relieving equipment to be used is included in the plans and this is good practice. The oral healthcare needs are not consistently documented and this requirement is outstanding from the last inspection. One care plan states that bed rails are required however they had not been fitted to the bed. Furniture and bedding was being used to prevent the person from rolling out and injuring herself. Where an assessment has indicated that bed-rails are required, these must be supplied and appropriately fitted according to the guidance produced by the Health and Safety Executive. The guidance on the use of furniture as restraint has been sent to the home.
West Lodge Care Home DS0000026478.V264409.R01.S.doc Version 5.0 Page 10 The qualified nursing staff administers medication. The medication administration records are generally good, however food supplements must also be signed to confirm they have been given. One person’s room contained a topical cream in a broken container and another that was not labelled with the residents name and did not have instructions as to how it should be applied. There were also personal toiletries belonging to another resident, including a body cream. The sharing of toiletries demonstrates poor infection control and puts people at risk, there are however liquid soap dispensers and paper towels in the rooms seen and this is good practice. One person confirmed she had undertaken infection control training but had not received her certificate. Her file did not contain a record that this training had taken place . West Lodge Care Home DS0000026478.V264409.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, 14, 15 Residents’ generally exercise choice and control over their lives. Activities are arranged on an ad-hoc basis. People enjoy the meals provided. EVIDENCE: One resident talked about how he spent his days. He prefers not get involved in many activities or leisure pursuits and stated ‘I spend my time doing the things I like to do’. During the handover, the staff were asked to do some activities with residents. These are unplanned and do not correspond with the limited information provided in the care plans concerning resident’s preferences. Two people said they enjoy the meals provided and the staff were observed sitting with individuals assisting them to eat. This has improved since the last inspection. One staff file contained a form detailing the protocol for feeding dependent residents. This was introduced in response to the previous inspection findings. West Lodge Care Home DS0000026478.V264409.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, 18. Complaints are acted upon appropriately and adult protection procedures are in place. EVIDENCE: The complaints records show that concerns have been documented and investigated. The procedure does need to give an indication of the timescales within which it will investigate concerns made. The local authority adult protection procedure has been adopted to ensure a proper response to any suspicion or allegation of abuse. The staff spoken with were confident about the action they will take if they suspected abuse however, one person could not identify the different types of abuse and need more information to enable them to recognise abusive situations. One person did not know what a Whistle Blowing policy was. West Lodge Care Home DS0000026478.V264409.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, 25 Residents are happy with the standard of their accommodation. Better management of maintenance records is required for the safe an efficient running of the home. EVIDENCE: Documentary evidence was seen that various systems within the home are appropriately maintained. This does not include the measures to minimise the risk of Legionella and scalds. The hoist is maintained however the company recommended some new parts and confirmation that this had been undertaken could not be located. One resident spoken with said he was very happy with the standard of his private accommodation. Priority should be given to the following: • There are no curtains in the lounge area. • There is a trip hazard on the floor from the lounge to the dining area. • Foliage is growing from the top of the skirting board in the office.
West Lodge Care Home DS0000026478.V264409.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, 29, 30. Adequate numbers of staff were working during the week of the inspection. Some progress has been made to ensure that staff records contain evidence of recruitment records. EVIDENCE: There is a trained nurse on duty during each shift. The home facilitates adaptation training for overseas’ nursing staff. One staff member confirmed that robust recruitment policies had been followed before she commenced work at the home. Her staff file contained only one written reference and a partly completed interview and induction checklist. Although some improvements have been made in the management of staff files however more work is required to ensure that the home can evidence robust recruitment and training practices are implemented. Some private staff documentation was found amongst papers in other files which is not in keeping with the Data Protection Act 1998. The two statements of terms of employment did not detail the employees name and date of commencement of employment. Documentary evidence of the training staff have undertaken was not well managed. One person confirmed she had undertaken infection control training but had not received her certificate. Her file did not contain a record that this training had taken place. She also confirmed receipt of in house moving and handling training using a video and instruction by senior staff. West Lodge Care Home DS0000026478.V264409.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): 37, 38. The CSCI was unable to make a judgement about the homes monitoring systems and the management of service users finances as relevant documentation could not be produced in the absence of the registered manager. These standards will therefore be assessed at the next inspection. The health and safety of service users and staff are generally well protected although the management of information regarding these and other issues could affect the effective and efficient running of the business. EVIDENCE: All of the files examined contained non-related material that had been misfiled. Many of the records are not in good order and this may affect the effective and efficient running of the business and does not offer people protection in accordance with the Data Protection Act 1998. One file contained personal information about a staff member. A comprehensive health and safety manual
West Lodge Care Home DS0000026478.V264409.R01.S.doc Version 5.0 Page 16 is in place. It contains a wealth of useful information and tools to manage and monitor health and safety in the care home. The resource has not been used to it’s full potential. The fire detection systems were inspected on 17/02/05. The lift was inspected on 05/08/05. The gas services were maintained on 15/06/05 and confirmation was seen that electrical systems are assessed four times each year. Confirmation is required that the hoist has been fitted with the recommended parts. One person who is dependent upon the staff to mobilise her had a tear to her skin. A statement had been obtained from staff in an attempt to establish how this had occurred. The daily records do not however mention this. One staff member received guidance on moving and handling from a video and from more experienced staff, another said that she had not yet received moving and handling training. The CSCI has not received Regulation 37 notifications of incidents affecting the wellbeing of residents in all cases. One care plan states that bed rails are required however they had not been fitted to the bed. Furniture and bedding was being used to prevent the person from rolling out and injuring herself. Where an assessment has indicated that bed-rails are required, these must be supplied and appropriately fitted according to the guidance produced by the Health and Safety Executive. The guidance on the use of furniture as restraint has been sent to the home. West Lodge Care Home DS0000026478.V264409.R01.S.doc Version 5.0 Page 17 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 1 1 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 2 X STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 1 3 West Lodge Care Home DS0000026478.V264409.R01.S.doc Version 5.0 Page 18 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 OP1 Regulation 4, 5 Requirement The statement of purpose and service user guide must be updated to include all of the elements in Schedule 1 of the Care Homes Regulations 2001. (This requirement remains outstanding from the last inspection) The statement of purpose must include the arrangements for providing day care at the home. (This requirement remains outstanding from the last inspection) Individual assessments must include how the residents oral health needs are to be met. (This requirement remains outstanding from the last inspection) Prospective residents must be informed in writing that the home can meet their assessed needs. (This requirement remains outstanding from the last inspection) The registered manager must produce an accessible medication policy and procedure
DS0000026478.V264409.R01.S.doc Timescale for action 31/03/06 2 OP1 4, 5 31/03/06 3 OP3OP7 14, 15 31/03/06 4 OP3OP4 14 31/03/06 5 OP9 13 31/03/06 West Lodge Care Home Version 5.0 Page 19 6 OP18 13 7 OP25 23 8 OP37 17 9 OP38 13 that details the recording, handling, safekeeping, safe administration and disposal of medicines and other prescriptions. The registered manager must ensure that staff are confident in their knowledge of abuse and of adult protection procedures. The registered manager must ensure: 1. The curtains are replaced in the lounge. 2. The trip hazard on the floor from the lounge to the dining area must be repaired 3. The cause of the foliage growing out of the top of the skirting board in the office must be identified and rectified. All records, in Schedules 3 and 4 must be kept up to date, in line with the Data Protection Act 1998, and accessible to the CSCI on inspection. The nature of the restraint in place must be accurately recorded and reviewed on a regular basis. 31/03/06 31/01/06 31/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The medication policy should be written in line with the guidance provided by the Royal Pharmaceutical Society of Great Britain entitled: The Administration and Control of Medicines in Care Homes and Children’s Services. The guidance provided by the CSCI regarding restraint
DS0000026478.V264409.R01.S.doc Version 5.0 Page 20 2 OP38 West Lodge Care Home should be implemented. West Lodge Care Home DS0000026478.V264409.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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