Inspection on 04/05/05 for West Point House

This inspection was carried out on 4th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

West Point House 09/01/08

West Point House 22/05/06

West Point House 04/10/05

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 4 May 2005 08:00 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 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 F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service West Point House Address Solway Drive Walney Island Barrow in Furness Cumbria LA14 3XN 01229 472356 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cumbria Care Pearl Carter Care Home 31 Category(ies) of 31 OP - Old Age registration, with number 10 DE(E) - Dementia over 65 of places West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. The home is registered for a maximum of 31 service users to include: up to 31 service users in the category OP - old age not falling within any other category up to 10 service users in the category DE(E) - dementia over 65. 3. The staffing levels in the home must meet the Residential Forum Care Staffing Formula for Older Adults. 4. 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. 5. 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. Date of last inspection 21 October 2004 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 Mrs 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 full access to the first floor. The home has four distinct living units, each with their own lounge, dining area and kitchenette. One unit is specifically for short term 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 accessible toilet and bathing facilities available to them. The home is in its own grounds with enclosed garden areas. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 4th May 2005 between 8am and 5pm. Time was spent with the residents, the manager and staff. In addition the inspector met with a visiting professional and resident’s relatives. Care plans and other information required for the running of the home was examined. All communal areas of the home and some resident’s rooms were also inspected. What the service does well: What has improved since the last inspection? What they could do better: A timetable for the redecoration of the home must be agreed to ensure all the work required is completed. Confidential information that is held on the individual units, to support and guide staff in their role, must be securely stored at all times. Staff were aware of their responsibilities in relation to hazardous substances, however some substances were not securely stored in the laundry. Staff meetings had taken place, however staff wanted them to be held more often, as they find them helpful for sharing important information. Staff levels West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 6 in the home have been at times below the required level. The home is trying to recruit new staff but must keep staff levels under review. The purchase of an answer machine is recommended so that messages relating to residents care can be left by other agencies. 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 F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 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 standard(s) 2, 3, 4. The home has good systems in place to ensure individual needs are assessed on admission to the home and on an ongoing basis. EVIDENCE: The majority of the referrals to the home are from the local social work team. Social work assessments were held on personal files, in addition the manager or supervisors will complete the home’s own assessment of needs, prior to admission, liaising with all significant parties. These provide the home with detailed information to compile a care plan that reflects individual needs and preferences. Soon after becoming resident the home completes a comprehensive functional assessment. Care plans are reviewed on a monthly basis. This ensures needs are monitored on an ongoing basis and appropriate referrals or other actions taken in response to changing needs. All the residents were issued with a detailed contract of terms and conditions containing all the relevant information required. The resident or their representative signed this. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 Personal and healthcare records were well maintained and accurate, ensuring a good, consistent quality of care was delivered. EVIDENCE: The home was in the process of transferring all care plans onto a new, more person centred format. Pertinent information was recorded, enabling staff to provide a consistent level of care. In addition to the care plan the home completed personal profiles, occupational ability assessments and functional assessments, giving staff detailed information regarding specific needs. There was evidence these were being reviewed on a monthly basis as required. The inspector met with the visiting district nurse, who has contact with the home on a daily basis. She confirmed the staff provide a “consistently high level of care”. She went on to say “They work closely with the community nursing service in meeting and responding to the healthcare needs of residents”. She also described how they provide formal training to staff in areas such as catheter care, diabetes care, pressure care and treating skin tears. Daily day/night care notes were completed at the end of each shift, which record and monitor all aspects of care and detailed any action taken and who had been informed or involved. Supervisors also completed a record of West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 10 significant events including all health related interventions, thus ensuring pertinent information was shared with relevant parties. Supervisors take responsibility for the management of medication in the home. One has already completed training and the other two are booked on the relevant course on the 9th May. New medication policies and procedures had recently been introduced in line with good practice. A working copy of the care plan is held on each unit, these were stored in a box file in the kitchenette. As these contain personal and confidential information they must be securely stored at all times in line with data protection guidelines. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15. Residents were supported and encouraged to lead fulfilling lifestyles of their choosing, opportunities however were sometimes limited by staff shortages. EVIDENCE: Although the home has four distinct living units, residents were moving freely between units to socialise or join in planned activities. Staffing levels on two units in particular, were impacting on the activities available to residents. Three days each week the large downstairs lounge was used to provide a day care service to existing residents but also to elderly frail people in the local community. Many of the day care residents had also used the short-term care facility and were known to the staff. Day care days were social occasions, in addition to providing people with stimulating activities. Recent activities included craft sessions with an Easter theme and a computer session with laptop computers being provided. Some residents were talking enthusiastically about a planned trip this weekend commemorating VE day. Staff were giving up their own time to support this activity, which typifies the commitment and dedication of the team, to provide a good quality service. The manager discussed her plans to appoint a member of staff who will be dedicated to facilitating appropriate activities throughout the home, in partnership with the existing staff. This should improve opportunities for people to participate in a variety of activities of their choosing. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 12 Staff had received specialist training in Dementia care, which they had found beneficial in supporting and guiding their practice in meeting people’s needs. They had a range of equipment at their disposal to provide a good range of age appropriate activities. The manager described how the home had purchased a large television for the main lounge, enabling them to have film shows and make an occasion of sporting events etc. when people can have a drink and relax. Based on discussions with staff and from the entries in the visitors book there were frequent visitors to the home. One relative spoken to, spoke positively about the service provided and “how obliging the staff were and how they always kept her informed.” The home has a four-week rolling menu, which provides a good level of choice at all mealtimes. In addition special diets are catered for with the cook having individual plans for residents with special dietary needs. The menu was currently being reviewed with seasonal alternatives planned. It was also evident that choices not on the menu were provided when requested. The inspector joined a group of residents for lunch. This was a freshly prepared home made meal. The residents spoken to confirmed that the quality and choice of meals was “good and that there was always plenty to eat”. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 13 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 standard(s) 16, 17, 18. The systems and policies in place protect resident’s rights and safeguard them from potential abuse. EVIDENCE: Through both induction and NVQ training, staff received training in relation to the mistreatment and abuse of vulnerable adults. Staff spoken to were aware of policies and procedures and knew their role and responsibilities in identifying and reporting events. Residents and relatives were aware how to complain and had been supplied with the relevant information. Financial systems in place were robust and safeguard residents from potential abuse. Only personal monies were held at the request of residents or their representative. These were securely stored and detailed records maintained to document all transactions, with receipts retained. The home liaises with a solicitor who acts on behalf of one resident. Some residents were being supported to attend the local polling station, whilst others preferred a postal vote. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26. The decoration in the communal areas of the home was poor but plans were in place to address the issues. EVIDENCE: Maintaining the decoration of the home has been an ongoing issue for the home for some time. The use of hot food trolleys too wide for the narrow corridors has caused problems by ripping wallpaper and chipping paint, which looks unsightly. These trolleys were due to be replaced with a smaller version. The manager explained that the organisations accommodation manager had visited the home to identify and agree a programme of repairs and renewal. However this was not available at the inspection and the manager did not think it contained timescales for completion of the work. The need for a detailed programme with timescales was confirmed with the manager. There was evidence of refurbishment of communal areas and private rooms, with some decoration completed and new furniture in place. Residents were pleased with the new chairs and they certainly improved the environment. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 15 Maintenance issues were discussed with the manager, new gates had been ordered for the enclosed garden, as the present gates were rotting and unsightly. The fridge door in the unit identified was in need of attention and the enclosed garden patio was infested with weeds and in need of remedial action. The broken panels on the perimeter fence and damage to the front lawn were also being addressed. Resident’s rooms were suitable with people personalising them with their own furniture and fittings. On the whole the laundry facilities were good, however on the day of the inspection COSHH substances were not securely stored. The laundry was visited in the morning and afternoon and on both occasions COSHH substances were present. Domestic staff were knowledgeable and aware of relevant procedures and the needs of residents that could be affected whilst undertaking their duties, such as trip hazards and handling COSHH substances safely. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30. The staff on duty were experienced and knowledgeable enabling them to meet individual needs. However staff recruitment remains problematical for the home. EVIDENCE: On the day of the inspection the home was one staff down due to a member of staff being on sick leave at short notice, there was also one agency staff working in the home. The home has experienced long term problems with recruitment and retention of staff, which can affect the quality of service to residents. The home has registered with a local employment/training partnership scheme, which supplies trainee staff to the home who have been unemployed for a long period or want a career change. The home follows their normal recruitment procedures and checks ensuring the safety and dignity of residents are maintained. After a full six week induction period incorporating formal training and shadowing regular staff, the trainees may be offered vacant posts. Currently the home has 105 hours vacant (5 posts). They are currently using two regular relief staff to cover vacant hours in addition to permanent staff picking up extra hours. Currently two units operate with one member of staff on duty, at key times this level of staffing is not adequate. As part of the current recruitment drive a third member of staff will be appointed to work between the units at these times. The home has developed personnel files for all staff including a continuous professional development plan. Individual training records were also maintained, including a copy of certificates of achievement and induction. The West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 17 home also uses an induction questionnaire to check out competence and understanding at the end of the induction process. Based on this information the manager develops a training development plan, to ensure training requirements are met within the required timescales. During the inspection the peripatetic NVQ assessor visited the home to carry out an assessment with a member of staff. Since the introduction of peripatetic assessors it was evident staff have made good progress with their NVQ awards, the sense of achievement making staff feel valued and motivated to put their learning into practice. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37, 38. The manager is well supported by senior staff in providing clear leadership. The manager and staff demonstrated a good understanding of their responsibilities and worked well as a team. EVIDENCE: The current manager has been at the home for three years, she has eighteen years experience in a supervisory position and is currently undertaking the registered manager award. Staff, visiting professionals and families felt the home was well run. With staff in particular saying they felt “valued by the manager and supervisors and that they all worked closely as a team”. This was evident during the inspection and was confirmed in the minutes of the staff meeting. Staff were disappointed that their commitment and the quality of the service delivered, was not fairly reflected through the organisations team briefing system, due to the ongoing environmental issues being present in inspection reports. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 19 Communication systems both within the home and with significant others were effective, however the home does not have an answer machine on the phone, which has proved problematical for other agencies trying to contact the home early in the morning. Staff did say that they would like the staff meetings held on a more regular basis as they felt they were a valuable method of communicating relevant information and supporting each other. A matrix, to plan, monitor and record formal staff supervision of all staff had been introduced to ensure supervision takes place in the required timescales. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 2 3 3 3 3 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 2 3 2 West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 21 Are there any outstanding requirements from the last inspection? 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. 2. Standard 37 19 Regulation 17(1)b 23 Requirement All personal and confidential information must be securely stored at all times. The manager must produce a detailed programme of repairs and renewal, with clear timescales for completion of the work identified. All parts of the home must be free from hazards to the safety of residents. Timescale for action 13.5.05 30.6.05 3. 38 13(4)a 6.5.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 36 38 27 Good Practice Recommendations It is recommended staff meetings are held on a more regular basis as agreed with staff. It is recommended the home purchase an answer machine to improve communication with other agencies. It is recommended the home keeps the staff levels under review at key times, in the areas identified. West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI West Point House F58 F10 s35574 west point house v219002 040505 ui stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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