Inspection on 22/05/06 for West Point House

This inspection was carried out on 22nd May 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 Point House 09/01/08

West Point House 04/10/05

West Point House 04/05/05

West Point House 21/10/04

West Point House 19/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE West Point House Solway Drive Walney Island Barrow in Furness Cumbria LA14 3XN Lead Inspector Ray Mowat Unannounced Inspection 22nd May 2006 08:00 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 Point House DS0000035574.V291189.R02.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 Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service West Point House Address Solway Drive Walney Island Barrow in Furness Cumbria LA14 3XN 01229 472356 01229 475750 pearl.carter@cumbmacc.gov.uk www.cumbriacare.org.uk Cumbria Care 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) Mrs Pearl Carter Care Home 31 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (31) of places West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 31 service users to include: Up to 31 service users in the category of OP (Old age, not falling within any other category) Up to 10 service users in the category of DE (E) (Dementia over the age of 65 years of age) The staffing levels in the home must meet the Residential Forum Care Staffing Formula for Older Adults. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing Wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. Two service users may share a bedroom of at least 16 sqm usable floor space only if they have made a positive choice to do so, when one of the shared Spaces becomes vacant the remaining service user has the opportunity to choose not to share, by moving to a different room if necessary. 4th October 2005 3. 4. 5. Date of last inspection Brief Description of the Service: West Point House is a residential care home registered to provide personal care and accommodation for thirty-one older people. It is owned and run by Cumbria Care, which is a division of Cumbria Contract Services, a Cumbria County Council business unit. The registered manager of the home is Pearl Carter. West Point is in a residential area of Walney Island, it is near to a bus route to the town of Barrow-in-Furness and within walking distance of local amenities. The property is a two-storey building, with a passenger lift providing access to the first floor. The home has four distinct living units, each with their own lounge, dining area and kitchenette. One of the units is specifically for shortterm care residents and another for people with dementia. It provides 29 single rooms, three of which have en-suite facilities and one double room, which two people can choose to share. All the units have West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 5 accessible toilet and bathing facilities available to them. The home is in its own grounds with enclosed private garden areas to the rear and ample car parking to the front of the building. The home provides a Statement of purpose and service user guide to prospective residents and the most recent inspection report is made available in the foyer of the home. At the time of this inspection the range of fees charged were from £317 to £422. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out early in the morning to enable me to see the morning routines of the home. I met with many of the residents during the day and also spoke to family members and other professionals visiting the home. A pre inspection questionnaire was completed and seven residents surveys were returned. I also met with the acting manager, the supervisors on duty and several care staff. What the service does well: What has improved since the last inspection? What they could do better: Information for people moving into the home must be improved so that people are aware of the rules of the home. Information about residents should be agreed with them and changed when their needs change. The home should look at how they can improve the storage of wheelchairs and the decoration of one of the units. Staff records and information should be checked to make sure they are up to date and accurate. Records of dangerous substances held in the home should be up to date. West Point House DS0000035574.V291189.R02.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 Point House DS0000035574.V291189.R02.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 Point House DS0000035574.V291189.R02.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): 1, 2, 3, 4, 5. Quality in this outcome area is adequate. The home must ensure new residents are given suitable information including a contract of terms and conditions. Good procedures are in place but not consistently applied resulting in some residents not being given all the relevant information they require. This judgement has been made using all available evidence including a site visit. EVIDENCE: It was evident from resident’s surveys, case tracking files and discussions with residents not all of them had received suitable information about the home prior to moving in. In addition some residents had not received or signed and agreed a contract of terms and conditions. This is subject to a requirement. There were both the home’s own assessment and social work assessments held on file, from which individual care plans had been developed. In most cases assessments were completed prior to admission, enabling both the resident and the service to make an informed choice about the suitability of the home to meet their needs. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 10 Some residents had either visited the home or stayed there on respite care prior to agreeing to move in. This had given them a valuable insight to life in the home and helped them make an informed choice. As one resident said “ It’s a big decision to leave your own home, but after I had tried it for a couple of weeks I decided it was the place for me”. This statement confirms the importance of having a planned and structured admission procedure that supports people through a difficult process. West Point House DS0000035574.V291189.R02.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, 10. Quality in this outcome area is adequate. Care plans are improving, however their quality and accuracy was inconsistent, which will impact on the consistency and quality of care for some residents. This judgement has been made using all available evidence including a site visit. EVIDENCE: Based on examination of residents care plans and personal files it was evident the care plans in the home are developing. Manual handling and general risk assessments are completed on admission to the home and kept under review. The home is introducing the use of resident’s profiles, which captures valuable information about their life and what is important to them. There was an excellent example of this where a key worker had worked closely with a family member and using photographs and written text had compiled a most informative social history. This document would be valuable for staff in gaining a better understanding about the person and valuing and respecting them as a unique individual. This type of work is good practice and it is recommended it be developed for all residents in the home. When case tracking three resident’s files it was noted that not all care plans were being agreed with and signed by residents or their representatives. This West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 12 is subject to a recommendation. Also some changes to people’s needs had not been updated as part of the care plan resulting in staff not being aware of and responding to changing needs. This included guidance relating to monitoring a residents weight and a change in personal circumstances. The home is required to ensure care plans are kept under review and updated as changes occur. The home has good relationships with the community health team with District Nurses visiting the home on a daily basis. During the inspection I met with the visiting consultant Psychiatrist. They confirmed that the home makes appropriate referrals to them and have the skills and knowledge to monitor and support people appropriately under their guidance. They also said staff had a good knowledge of the individual and psychological needs of residents. I discussed the orientation of people with dementia with some of the staff. They were aware of the need to do this but did make suggestions how this could be improved. It is recommended good practice in this field is researched and practice within the unit reviewed. Daily records are maintained by the home that ensures good continuity among the staff team. In addition there is a shift handover to ensure all relevant information is passed on. A good example of this was contained in resident’s daily notes, which read, “ Resident upset tonight reassurance and time to talk were given”. I checked the contents of one of the medication trolleys against the home’s records. The majority of the medication administered was held in a monitored dosage system, the remainder being in the prescribing pharmacist’s container. The medical record sheets (MAR charts) were up to date and accurate and the stocks held were appropriate. I observed the supervisor on duty administering medication who was supported by a second member of staff who is a “quality checker”. Good practice was observed and both staff had received training to support and guide their practice. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 13 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, 15. Quality in this outcome area is good. Residents enjoy a fulfilling lifestyle to the maximum of their abilities. Their rights and choices are respected by staff with individual needs acknowledged. This judgement has been made using all available evidence including a site visit. EVIDENCE: On the day of the inspection one of the units was being thoroughly cleaned, which meant normal routines were changed and residents had to spend time in a different unit. However this was managed effectively without any adverse effects on the residents. During my discussions with residents they talked about the activities they enjoy, which included a sing-along, bingo, chair exercises, quiz, craftwork/hobbies as well as socialising with each other. Staff said how sometimes they would have impromptu reminiscence sessions just by asking a few simple questions through knowing something from someone’s past. This confirmed the value of having detailed social histories and personal profiles. As a result of feedback from the regular residents surveys the home appointed an activities co coordinator who organises and facilitates activities in each unit on a daily basis, with sessions held in the day service room on two days each week when it is not in use. This enables a larger group of people to come together for a group activity or social gathering. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 14 There are frequent visitors to the home who confirmed they are always made welcome. Residents are supported to pursue their own interests both in the home and in the community. One resident said, “Nothing is too much trouble for the staff, we have a laugh and get together for activities and chats, my favourite is countdown it keeps my brain active”. It was evident residents have a large degree of control over their lives with staff supporting and encouraging independence. Good examples observed included encouraging mobility and support with eating a meal. Care plans record individual’s dietary requirements including specialist diets such as diabetes or gluten free diets. Each morning residents are able to choose their meals for the day, with individual choices reflected in the home’s records. Menus contained a good range of fresh and nutritious food. The recording of people’s food intake and weight was inconsistent, when fluctuations in weight occur a record of the actions taken must be maintained. This issue has been addressed in standard 7. I joined a group of residents for lunch on one of the units. This was served from a hot trolley and was well presented. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 15 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. Quality in this outcome area is good. The home’s policies, procedures and practice ensure residents are safeguarded and their complaints are heard and responded to. This judgement has been made using all available evidence including a site visit. EVIDENCE: Staff spoken to were aware of their responsibilities with regard to recording and reporting complaints. Information about how to complain is displayed in the home and feedback from the resident’s surveys said people were aware how to complain and who to complain to. There were no recorded complaints since the last inspection. The home has ongoing training with regard to mistreatment and abuse policies and procedures. There was a good awareness among the staff of their responsibilities in identifying and reporting abuse. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 16 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, 20, 21, 22, 25, 26. Quality in this outcome area is adequate. An annual condition survey is completed by the organisation to identify remedial work required. This work should now be planned and timescales agreed so that work is completed in a timely manner and the environment is suitably maintained. This judgement has been made using all available evidence including a site visit. EVIDENCE: All the areas of the home I visited on this occasion were clean and hygienic. Due to a recent outbreak of sickness and Diarrhoea each area of the home was being systematically cleaned, which is good practice. The home have created a designated smoking room at the front of the building, which enables people to enjoy a smoke without the smoke getting into the rest of the home. The laundry was well ordered and there were no obvious hazards. All other communal areas of the home were well-maintained and free from hazards although one of the bathrooms was being used for the storage of several West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 17 wheelchairs. This was a potential hazard and should be reviewed and alternatives explored. This is subject to a recommendation. The wallpaper in one of the lounge/dining areas is ripped and worn and in need of replacement, in the same unit place mats for the tables are also worn so cannot be readily cleaned and should be replaced. The roof in the kitchen had developed a leak, which was being attended to on the day of the inspection. There are suitable aids and adaptations in place around the home in addition to individual pieces of equipment that help maintain independence. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 18 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. Quality in this outcome area is good. There is an appropriate number of welltrained and knowledgeable staff, who are working well together to meet the needs of residents. This judgement has been made using all available evidence including a site visit. EVIDENCE: Since the last inspection the home has recruited to all the vacancies and is now operating with a full compliment of staff. Based on discussions with residents and staff this has had a positive effect on the quality of life for residents and the morale of the staff. There was a healthy “rapport” between staff and residents and several residents I spoke to complimented the staff on their “attitude, helpfulness or cheerfulness”. Staff said they got “Good training” and had completed “a full induction”. Supervision records were examined and confirmed that supervision is held on a regular basis and the content of the discussions were appropriate to support and guide them in their role. Staff files and training records were in place for all staff, however their content is inconsistent and should be audited to ensure all relevant information is held. The home’s recruitment procedures are in line with current good practice and all necessary checks had been completed for the current staff group on the list provided on the pre inspection questionnaire. I met with several staff on a one to one basis as well as talking to them as they went about their duties. They were consistent in their responses, which I West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 19 think are summed up by this response, “We are a good team with staff and supervisors working together, it’s a nice place to work”. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 20 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, 32,33, 35, 36, 37, 38. Quality in this outcome area is adequate. Despite the absence of the manager the home is operating effectively and staff feel well supported. Some records are not up to date or in line with the requirements of the Care Home Regulations. This judgement has been made using all available evidence including a site visit. EVIDENCE: The registered manager is currently on a long-term absence, however a manager from a nearby home is overseeing the management of the home on a day-to-day basis, working closely with the team of supervisors. It was evident from feedback from residents, staff and other professionals the home is operating effectively and people’s needs are being met. Staff said they were getting good support and clear guidance when required. Staff meetings are held on a regular basis and I sampled the minutes of the most recent meeting. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 21 “Customer satisfaction” surveys are given out on a rolling programme throughout the year to residents and relatives. Feedback from these is discussed at residents meetings or responded to individually. Issues raised at a recent residents meeting had been acted upon, which is good practice and also ensures the home is being run in the best interests of residents. As I mentioned previously an activities coordinator was appointed as a direct result of feedback from a quality assurance survey. It is acknowledged improvements have been made with regard to residents and staff records and new systems introduced, however these must be continued and good practice recommendations responded to. There was no COSHH data sheet for some cleaning fluid being used in the kitchen although there were data sheets for similar substances. It is recommended the COSHH file is reviewed and updated. On the whole West Point House provides a safe and comfortable environment that is meeting the needs of residents. West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 22 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 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 2 West Point House DS0000035574.V291189.R02.S.doc Version 5.1 Page 23 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 OP2 Regulation 5 Requirement Residents and prospective residents must be provided with suitable information including a signed contract of terms and conditions. The home must ensure care plans are kept under review and updated as changes occur. Timescale for action 31/07/06 2 OP7 15(2) b 31/07/06 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 2 3 3 4 Refer to Standard OP7 OP7 OP8 OP38 OP19 Good Practice Recommendations It is recommended the home develop personalised care plans for all residents including a personal profile/social history. It is recommended that all care plans are signed and agreed with residents or their representatives. It is recommended good practice in dementia care is researched and practice within the unit reviewed. All areas of the home should be free from hazards to the resident’s safety. It is recommended the decoration of the lounge (Tummer) DS0000035574.V291189.R02.S.doc Version 5.1 Page 24 West Point House 5 6 OP37 OP38 be completed as part of the annual programme of repairs and renewals. Staff files and training records should be audited to ensure they contain all relevant information. It is recommended the COSHH file is reviewed and updated. 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