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Inspection on 10/04/06 for West Lodge Residential Care Home

Also see our care home review for West Lodge Residential Care Home for more information

This inspection was carried out on 10th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents appeared happy, relaxed and comfortable during the course of this inspection. They chatted happily with the inspector about their experiences of living at West Lodge. Most residents spoken with praised the food and were observed eating their midday meal with relish. One resident praised the staff and said they were "kindness itself" and "they always treat me with respect" One relative spoken with subsequent to this inspection visit reported that they always turn up at the home unannounced and the staff were always very pleasant with coffee being served coffee served to them without even being asked. It was reported that the relative`s room was always "spick and span" and that their relative was "always clean tidy and happy".

What has improved since the last inspection?

Since the last inspection the small lounge had been pleasantly refurbished providing a quiet area for the residents to receive guests in private. This room had also a concealed basin fitted with a showerhead to accommodate the fortnightly hairdressers visit. 4 new beds had been purchased for residents since the previous inspection visit and the registered manager reported that there was an ongoing project to redecorate and refurbish residents` rooms. General cleanliness of the home had improved since the previous inspection visit as a result of an increased domestic staff provision.

What the care home could do better:

The safety and welfare of residents would be better protected if all staff were reminded of the policies and procedures in place for admitting visitors to the home. Residents` and family/representative input into the formulation and revision of care plans would further protect the best interests of the residents. During the course of this inspection the inspector witnessed conversations between staff members that did not serve to protect the residents` privacy or dignity. The previous inspection contained a repeat requirement for the provision of appropriate social activity specifically designed to meet the needs of residents with Dementia. The registered person had made some progress in this area at the point of this inspection, however this was still work in progress. At the previous inspection there had been an offensive odour throughout the home. On the day of this visit this had not improved. The registered provider reported that an `odour neutraliser` had been ordered and training was to be arranged for staff. The safety and welfare of residents and the staff team would be better maintained if the registered manager were able to work appropriate shifts to fulfil her managerial role. Recent staff shortages had resulted in the manager working her shifts as a carer and matters such as staff supervision, organising the staff training programme and researching meaningful activities for people with dementia had suffered as a result. The registered manager further promoting NVQ 2 training amongst the care staff team would better protect the health, safety and welfare of the residents. The registered person would further protect the safety and well being of the residents by developing the home`s recruitment practices to include written references as opposed to a tick box format and expanding the application forms/request a cv in order to provide a full work history of the applicant in order that any gaps in employment may be explored.

CARE HOMES FOR OLDER PEOPLE West Lodge Residential Care Home 32 Palmerston Road Buckhurst Hill Essex IG9 5LW Lead Inspector Jane Greaves Unannounced Inspection 10th April 2006 10:00 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 Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 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 Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service West Lodge Residential Care Home Address 32 Palmerston Road Buckhurst Hill Essex IG9 5LW 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) 020 8504 4542 02085 044542 Dr S Seyan Mr J Kotecha Mrs C J Knight Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (19) of places West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 19 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 19 persons) The total number of service users to be accommodated in the home must not exceed 19 persons 17th October 2005 Date of last inspection Brief Description of the Service: West lodge is a large detached property in Buckhurst Hill, which offers residential care to 19 people over the age of 65 years of age. The home is also registered to accommodate individuals who suffer from Dementia. There are 15 single rooms and 2 double rooms. There is a passenger lift to the first floor and a stair lift to a mezzanine floor. To the rear of the property there is a garden and a car park. The home is accessible by public transport and there are shops and amenities nearby. A copy of the most recent report by Commission for Social Care Inspection was displayed in the entrance hall and a copy of the home’s service user guide including a statement of purpose was present in service users’ rooms. Information from the registered provider received by the commission on 10th February 2006 showed that the fees payable range from £443.00 to £475.00 per week. Additional charges are made for services as Chiropodist (£7.50), Hairdresser (£6.00 to £30.00) and daily papers. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over 6 ½ hours one day in April 2006. A member of the care staff let the inspector into the building. This member of staff did not have a good command of the English language and did not ask for identification or establish who the ‘visitor’ was. Residents were dressed and were sitting happily in the communal lounge listening to music. 21 of the 38 National Minimum Standards were assessed at this visit and 12 were met. A tour of the premises was undertaken, records were examined, staff and residents spoken with and some family members were consulted following the inspection visit as part of this inspection process. The inspector appreciated the assistance received with the inspection process by the home’s manager, the staff team and the residents. What the service does well: What has improved since the last inspection? West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 6 Since the last inspection the small lounge had been pleasantly refurbished providing a quiet area for the residents to receive guests in private. This room had also a concealed basin fitted with a showerhead to accommodate the fortnightly hairdressers visit. 4 new beds had been purchased for residents since the previous inspection visit and the registered manager reported that there was an ongoing project to redecorate and refurbish residents’ rooms. General cleanliness of the home had improved since the previous inspection visit as a result of an increased domestic staff provision. What they could do better: The safety and welfare of residents would be better protected if all staff were reminded of the policies and procedures in place for admitting visitors to the home. Residents’ and family/representative input into the formulation and revision of care plans would further protect the best interests of the residents. During the course of this inspection the inspector witnessed conversations between staff members that did not serve to protect the residents’ privacy or dignity. The previous inspection contained a repeat requirement for the provision of appropriate social activity specifically designed to meet the needs of residents with Dementia. The registered person had made some progress in this area at the point of this inspection, however this was still work in progress. At the previous inspection there had been an offensive odour throughout the home. On the day of this visit this had not improved. The registered provider reported that an ‘odour neutraliser’ had been ordered and training was to be arranged for staff. The safety and welfare of residents and the staff team would be better maintained if the registered manager were able to work appropriate shifts to fulfil her managerial role. Recent staff shortages had resulted in the manager working her shifts as a carer and matters such as staff supervision, organising the staff training programme and researching meaningful activities for people with dementia had suffered as a result. The registered manager further promoting NVQ 2 training amongst the care staff team would better protect the health, safety and welfare of the residents. The registered person would further protect the safety and well being of the residents by developing the home’s recruitment practices to include written references as opposed to a tick box format and expanding the application forms/request a cv in order to provide a full work history of the applicant in order that any gaps in employment may be explored. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 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 Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 8 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 Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 9 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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No resident moved into the home without a full assessment of their needs being made and being assured that these would be met. West Lodge did not accommodate residents referred solely for intermediate care. EVIDENCE: Care plans of the most recent admissions into the home were sampled at this visit; all included an appropriate Social Services Department assessment. The registered manager met with the resident before receiving them into the home to undertake a comprehensive pre admission assessment covering such areas as their physical, emotional, spiritual, social and care needs. This assessment formed the basis of the care plan and was developed and expanded further throughout the month trial period afforded to each new resident. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 10 All residents’ files observed at this visit contained adequate care plans. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 11 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, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ health, personal and social care needs were set out in an individual plan of care however lacked the detail required for the residents to be confident their individual social an recreational needs would be met. Residents’ could be assured their health needs would be met. Residents were protected by the home’s policies and procedures for dealing with medicines. Residents’ dignity and respect was not always protected by the day to day practice within the home. EVIDENCE: Information contained within the care plans was basic, not accurately reflecting the complex needs of the residents living at the home. There was no evidence available to show that residents or their relatives were involved in the care planning or review processes. The manager reported that relatives, social West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 12 workers and GPs were invited to participate in care plan reviews however seldom embraced the opportunity. Two residents’ families spoken with subsequent to this inspection visit reported that they had not been invited to any reviews of their relatives’ care plans. The inspector was shown a standard letter that was sent to each resident’s representative inviting them to participate in the care plan reviews. Personal care tasks were not always detailed in the care plans, although it was clear from observation on the day that staff and management promoted independence with personal care wherever possible. Copies of the home’s Service User Guide, Statement of Purpose and the contract between the home and the residents were maintained in files in the residents’ rooms. The documents sampled at this visit did not include signatures of the residents, their representatives or the management of the home. The registered manager reported that all residents had been made aware of advocacy services but had chosen not to avail themselves of these. A group discussion with 12 residents took place during the afternoon of the inspection and it was apparent that most residents did not understand what advocacy services were and how they could help them. The home operated under robust policies and procedures for the safe storage, receipt and administration of medication. No resident at the home was able to take responsibility for self medication. Procedures observed on the day were appropriate to protect the health and safety of the residents. Recording of medication was appropriate with no gaps evident on the MAR sheet. All staff reported having received regular medication training with annual refresher updates provided however, the registered manager had not obtained certificates to provide evidence of the pharmacy led training that staff reported receiving late 2005. It was reported that an alternative pharmacy supplier had been secured and further training was scheduled to take place. A Chiropodist was attending the home on this day and was treating the residents’ feet in the communal lounge area. It was confirmed that this was normal practice. Staff members reported that the residents were happy for this to take place however, discussion with residents showed that whilst they were happy to receive attention from the Chiropodist in public they were not so happy with having to watch other residents receive treatment in this manner. The resident group stated they were not keen to retire to their own rooms for Chiropody treatment and the use of the small newly refurbished ‘quiet’ lounge/hairdressing salon for this task was discussed with the residents. The group felt that this was an acceptable compromise as it protected their dignity. During the afternoon activity time staff members were observed calling loudly across the busy communal lounge to enquire if individuals had the need to visit West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 13 the bathroom. This practice did not serve to protect the residents’ dignity or show them respect. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 14 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, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoyed their life at west Lodge but did not always find the lifestyle matched their recreational interests and needs. Overall the home provided the residents with flexibility and choice with regard to their daily lives. The residents individual dietary needs were catered for with a wholesome and balanced menu. EVIDENCE: Residents happily chatted to the inspector about their lives at West Lodge. The majority of the comments made were positive in nature but just one area they mentioned, activities and pastimes, fell short of their expectations and preferences. Residents appreciated the time that staff members dedicated to entertaining them but felt that there was little variety. A group of seven residents were observed to take part in a general knowledge quiz on the afternoon of the inspection. There was much laughter and it was good to see the animated expressions on the faces of the participants. The residents themselves were not able to suggest activities they would like to do however individual care plans included a ‘list’ of leisure preferences, there was no West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 15 evidence to confirm that these identified individual choices had been explored. The ‘one size fits all’ approach did not adequately address the diverse needs of individuals. The registered manager and registered provider reported various ideas for future activities and were advised to research specific activities for those residents with dementia. Family members spoken with as a result of this inspection confirmed they were welcomed at the home any time day or night. Residents confirmed they could receive visitors in the privacy of their own room, in the quiet lounge or in the communal lounge area. Some relatives accompanied their loved ones on Theatre trips organised by the home. As mentioned previously in this report it had been said that the residents at West Lodge had chosen not to avail themselves of advocacy services. Some residents did not have regular family/representative support and did not understand what advocacy services were. The registered manager was advised to secure some external support for these vulnerable people. The pre-inspection information provided by the registered person demonstrated that just one main meal alternative was available for a week. The example provided was that every day for a week the main meal alternative was steamed fish. Staff reported that this was not a true reflection of the situation and that if any resident was not happy with the meal of the day it would be replaced with a meal of their choice, this was confirmed during discussions with residents. The registered person was advised that records should reflect this. One resident needed their food to be served pureed. It was observed on the day that Corned Beef hash and cabbage when pureed was not an appetising picture. Discussions took place with the cook and the registered manager regarding pureeing the various elements of the meal separately in order that the resident would be able to recognise and enjoy the different flavours of the individual foods. Staff and residents confirmed that snacks and drinks were available outside mealtimes. The Kitchen floor had stubborn stains around the edges. The cook reported that the floor had been steamed in order to try and remove this staining. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 16 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives could be confident that their complaints would be listened to, taken seriously and acted upon in accordance with the home’s complaints policies and procedures. Residents were protected from abuse. EVIDENCE: Records showed that no complaints had been received by the home since the previous inspection. The home had robust policies and procedures in place to ensure residents and their families/representatives/staff members were aware of how and to whom to complain to should they become dissatisfied with the care provided at West Lodge. Staff members at West Lodge received induction training that included the protection of Vulnerable Adults from abuse. Annual refresher training in this area had been provided for the majority of care staff. It was a matter of concern that a member of care staff granted the inspector entry to the home on arrival without knowing who she was, asking for identification or who she was there to see. The inspector was left to wander West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 17 around the home until a senior staff member noticed her when emerging from a resident’s room. Monies maintained by the home on behalf of residents was checked and found to balance with records that were well maintained. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 18 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents lived in a safe well maintained environment. The residents would benefit from the home being free from unpleasant odours. EVIDENCE: Since the previous inspection visit it was reported that 4 new beds had been provided for residents as part of the refurbishment and redecoration programme. It was reported that a further 4 rooms (numbers 2, 5, 14 and 18) remained on the list for refurbishment. The floor covering in five residents’ rooms had been replaced with domestic lino with a homely design. In one of these rooms the flooring was noted to be lumpy and stretched. The registered provider attended to this shortfall immediately after receiving the feedback. This unsightly potential hazard had West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 19 not been reported on the regulation 26 reports submitted to the commission by the provider. A small communal ‘quiet’ lounge had been refurbished including new laminate flooring, a coal effect electric fire, new armchairs and painting and decorating. There was a false cupboard front and hidden from view was a dedicated hairdressing sink complete with built in shower attachment for the fortnightly visit by the hairdresser. On arrival at the home there was an over powering smell of urine present that pervaded throughout the unit. This had been identified at the previous two inspection visits. The registered manager reported believing this was exacerbated by the fact that according to District Nurse assessments each resident was only entitled to one incontinence pad over night time. Discussions took place with the registered manager and registered provider about different mechanisms of dealing with this issue. It was reported that an odour neutraliser had been ordered together with training in eliminating offensive odours from the home for the staff team. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 20 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 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Sufficient staff members were not available at all times to meet the residents’ individual needs in a timely manner. Residents health, safety and well being were not protected by an appropriately qualified staff team. The home’s recruitment practices did not protect the safety of the residents. EVIDENCE: The registered manager reported suffering staff shortages due to sickness of permanent staff members. The manager only had two shifts per week dedicated to the management responsibilities of the home however had been working as a member of the care staff to meet the staffing levels required for the unit. It was reported that just one shift per week had been dedicated to the management role recently however other sources reported that this was an optimistic view. Discussions took place with the registered manager and registered provider outlining their responsibilities to ensure the home is run in the best interests of the residents. The staff training programme, residents’ activity programme, odour control within the home and care plans would benefit from more management hours and this would further protect the health, safety and welfare of the residents. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 21 Domestic staffing provision had been increased as a result of previous inspection requirements; the registered manager reported an improvement of the cleanliness and hygiene of the home. A tour of the premises prompted the inspector to concur with this judgement apart from the odour control. Mandatory training and regular annual refresher training had been provided for the majority of staff members, some individuals had not been available to attend some of the courses. The desired ratio of 50 of care staff trained to NVQ level 2 was not achieved by the target date of December 31st 2005, the registered manager and registered provider assured the inspector that they are addressing this shortfall however some staff members reported they had achieved their qualification but the certificate had not been provided. The registered manager was advised to be more pro-active in obtaining certificates to validate the staff team’s achievements. Staff recruitment files sampled at this visit contained evidence of application forms, personal references and identification papers. Some references were in a ‘tick box’ format and did not allow for the referee to provide much detail. The pre-inspection information showed that one staff member commenced work at the home before an enhanced Criminal Bureau Disclosure had been received. The registered manager reported that the registered provider had secured a PoVA 1st clearance for this person before they started to work at the home. The registered manager was advised that evidence to confirm actions of this nature must be maintained on the relevant staff file. The registered provider forwarded a copy of the PoVA 1st clearance to the inspector before the inspection processes were completed. Staff application forms were basic and did not include sufficient space for applicants to provide a complete employment history. The registered manager was advised to expand the present application forms or to request that a full CV accompanied the completed application forms. Training had been provided for staff members addressing all mandatory areas and some service specific areas. The registered manager was advised that all staff members must attend mandatory training including those working night shifts. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 22 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): 31,33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lived in a home run and managed by a person who was fit to be in charge and of good character, however insufficient hours have been dedicated to management responsibilities. The home was run in the best interests of the residents. Residents’ financial interests were safeguarded. The health safety and welfare of the service users was promoted. EVIDENCE: The registered manager had the appropriate qualifications and experience for the role. As mentioned previously in this report various discussions took place West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 23 with the registered provider and registered manager regarding the hours dedicated to the management role and responsibilities at this unit. Rota’s and staff members confirmed that the registered manager had not been able to maintain the two shifts per week allotted for management duties, as the home had been short staffed. This situation had impacted on the residents as staff training, staff supervision, care planning and other management duties had taken a back seat. The registered provider was able to demonstrate that some quality assurance had been undertaken since the previous inspection. The majority of the residents at West lodge did not have the cognitive awareness to complete the service questionnaires themselves and many did not have family/ representatives available to complete them on their behalf. Overall, family members spoken with directly as a result of this inspection were generally pleased with the service the home provided for their loved ones. Service users’ finances maintained by the home were balanced and agreed as part of the inspection process. Records accurately reflected the funds held and provided a clear audit trail to provide evidence of transactions. Certificates were available to provide evidence that health and safety checks were undertaken as routine at West Lodge. There were no outstanding health and safety issues observed or noted at this visit. West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 25 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 OP7 Regulation 15(c)(d) Requirement The registered person shall and, unless impractical to carry out such a consultation after consultation with the service user/representative, revise the service user plan and notify the service user/representative of any such revision. Timescale for action 31/05/06 2. OP10 12(4)(a) 3. OP12 16(2)(n) This specifically refers to obtaining evidence of service user/representative input into the formulation and revision of care plans. The registered person shall make 10/04/06 suitable arrangements to ensure that the care home is conducted in a manner, which respects the privacy and dignity of service users. This is a repeat requirement that did not meet the original agreed timescale of 17/10/05 The registered person shall, 31/05/06 having regard to the size of the care home and the number and needs of service users, consult service users about the programme of activities arranged DS0000017995.V288755.R01.S.doc Version 5.1 Page 26 West Lodge Residential Care Home by or on behalf of the care home, and provide facilities for recreation including, having regard to the specific needs of individual service users, appropriate activities in relation to recreation and fitness. This refers specifically to the needs of individuals with dementia. This is a repeat requirement that did not meet the original agreed timescale of 31/12/05 The registered person shall make 10/04/06 arrangements, by training staff or other measures, to prevent service users being harmed or suffering abuse or being placed at risk from harm or abuse. This specifically refers to the security arrangements for admitting visitors into the home. The registered person shall, having regard to the size of the care home and the number and needs of service users, keep the care home free from offensive odours. This is a repeat requirement that did not meet the original agreed timescale of 31/10/05 The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of the service users. This specifically relates to DS0000017995.V288755.R01.S.doc 4 OP18 13(6) 5. OP26 16(2)(k) 31/05/06 6. OP27 18(1)(a) 10/04/06 West Lodge Residential Care Home Version 5.1 Page 27 7. OP28 18(1)(a) management hours being worked as care hours. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of the service users. This specifically relates to care staff achieving their NVQ level 2 The registered person shall not allow a person to work at the care home unless he has obtained in respect of that person written references as referred to in Schedule 2 paragraph 5 and that he is satisfied on reasonable grounds as to the authenticity of the references in respect of that person. This specifically refers to obtaining two written references and validating their authenticity. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers are appropriate for the health and welfare of service users. This specifically refers to the staffing shortages that have resulted in the loss of dedicated management hours. DS0000017995.V288755.R01.S.doc 31/07/06 8 OP29 19(4)(c) 10/04/06 9 OP31 18(1)(a) 30/04/06 West Lodge Residential Care Home Version 5.1 Page 28 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 OP15 Good Practice Recommendations It is a recommendation of good practice that where residents’ assessed needs dictate that their food must be liquidised this should be done as separate elements in order that the resident may enjoy the different tastes and flavours of the food. It is a recommendation of good practice that the registered person further develops the home’s employment application form to allow for more detail in order that any gaps in the applicants work history may be explored. 2 OP29 West Lodge Residential Care Home DS0000017995.V288755.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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