Inspection on 04/10/05 for West Point House

This inspection was carried out on 4th October 2005.

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

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

Other inspections for this house

West Point House 09/01/08

West Point House 22/05/06

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 04 October 2005 07:30 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.V253523.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 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.V253523.R01.S.doc Version 5.0 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 spacde 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 May 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 accessible toilet and bathing facilities available to them. The home is in its own West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 5 grounds with enclosed private garden areas to the rear and ample car parking to the front of the building. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place at 7.30am on the 4th October 2005. This enabled the inspector to meet with two night staff as they were finishing their shift. In addition the inspector formally interviewed three care staff on duty during the day. During the course of the inspection the inspector met with many of the residents, in the communal lounges or in their own rooms. Visitors to the home were also spoken to, including family members and a visiting District nurse. As part of the inspection three service users files were “case tracked”, this is a process that involves meeting the service user and closely examining all information held by the agency relating to them, ensuring that the plan of care is being provided as required. What the service does well: What has improved since the last inspection? What they could do better: The secure storage of COSHH substances must be maintained at all times. Although care plans contained detailed information relating to health and personal care issues, they should also contain information relating to individuals interests and hobbies. In addition particularly for people with dementia, a social history or pen picture should be in place, to give staff an insight into individuals life experiences, personalities and valued roles they have undertaken. Care plans should also be reviewed, agreed and signed by residents or their representatives. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 7 The inconsistent provision of structured activities has been an issue that both residents and staff have raised. With the recruitment of new staff to the vacant posts this should improve. At mealtimes residents should be encouraged to maintain skills and independence, through serving themselves if they are able. 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.V253523.R01.S.doc Version 5.0 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.V253523.R01.S.doc Version 5.0 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, 3, 5. The home has a clear and effective admissions procedure, ensuring individual needs are assessed and that the home can meet them. EVIDENCE: Many of the new residents to the home have either used the respite service, or were familiar with the home’s services, through a visit or by being supplied with pertinent information. The home works closely with the social worker, prospective resident and or their relative/representative, to ensure a full assessment of need is in place, to enable an informed decision to be made. Care plans for people using the respite service were examined, these also contained relevant information, to support and guide staff in providing a personalised service. The home will take emergency admissions into the respite service, however these are kept under review, ensuring that needs are appropriately met. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10, 11. Care plans were inconsistent and are in need of review, ensuring they contain pertinent information relating to individual needs, particularly for people with dementia and communication difficulties and should also incorporate people’s social interests. EVIDENCE: All the residents had a care plan in place based on the initial and ongoing assessments. A functional assessment is completed each month, which is used as a review of the care plan. However when changing needs were assessed, they were not always being incorporated into the care plan. The care plans contained detailed information relating to personal and healthcare needs, however they could be improved with information relating to the individual, their hobbies and interests and the support people require in pursuing them. In addition the care plans for people with dementia would benefit from similar information, in addition to a social history or pen picture. This is particularly important for people with memory loss or other communication difficulties, as it provides staff with a valuable insight into people’s lives, personalities, relationships and the valued roles they have West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 11 enjoyed. Training in dementia care mapping would be beneficial to staff working in this unit. One of the care plans examined was for a person with speech/communication difficulties, these were not recorded in any detail and did not support and guide staff, in understanding and responding to the resident. All healthcare needs and interventions were well documented, with daily care notes and supervisor records being used to monitor and maintain a continuity of care. Based on discussions with residents and their relatives and from the inspector’s own observations of care practices and interaction, people’s privacy and dignity were being respected. The home had identified a training need for staff in relation to supporting the dying and bereaved and in response had recently held an in house training session. Suitably qualified supervisors led the sessions using a training video and work sheets, which had proved an effective method and was enjoyed by staff. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 12 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. Staff shortages have had a negative impact on the ability of the home to provide appropriate activities for residents. Independence should be promoted at mealtimes. EVIDENCE: The inspector spent time in each of the units as people were getting up, although staff were busy there was a relaxed atmosphere. It was evident people were getting up in their own time and either making their way to the kitchenette or having breakfast in their own room. Some residents were seen to be waiting for quite long periods before breakfast was served to them. If cereals and milk were made more accessible to them on the tables, people would have been able to help themselves, therefore maintaining skills and independence. One group of residents spoken to said they “enjoyed afternoon activities, although they do not always take place”. These issues were discussed with staff that mirrored the frustration of the residents, as due to the staff shortages they were not able to provide regular activities. Based on the minutes of the staff and residents meetings these issues had been discussed at length. The manager was aware of the problem and felt that with the recruitment of new staff to all the vacant positions in the home, they would be able to improve the situation. In the mean time the manager has identified a West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 13 member of staff to take a lead role in consulting with the residents and planning and facilitating appropriate activities. It was evident the staff team were committed to improving the situation and were planning a series of fund raising events, to fund some special events or trips. This is a good example of the conscientiousness of staff within the home to provide a quality service. It is recommended the home continues this process and keeps the situation under review, ensuring an appropriate range of activities are provided. The inspector joined a group of residents for lunch on one of the units. This was freshly prepared and well presented. The menus reflected a varied and balanced diet, with special diets and requests catered for. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 14 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, 17, 18. The home has sound systems in place to safeguard residents. EVIDENCE: There have been no recorded complaints since the last inspection. There had been a recent notifiable incident relating to the loss of some monies from the home. This had been reported to the relevant authorities in a timely manner and a full investigation and report completed. The report included recommendations to improve the security in the office and earlier detection of errors, which had been implemented. In addition to formal training for staff, relating to mistreatment and abuse, the home was using a training video and work sheets, to improve and maintain staff awareness. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 15 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, 22, 25, 26. Although some improvements have taken place since the last inspection, further decoration and alterations are required to the environment. EVIDENCE: The manager supplied a copy of the home’s condition survey, which identified planned decoration and repairs. The smaller heated food trolleys and the gates to the gardens were still not in place, however the manager assured the inspector they were on order and awaiting delivery. Once these are in place a priority list for decoration should be produced. New carpets had been laid in one of the main lounges and three bedrooms, with plans for another lounge to be completed. Some of the corridor carpets were in need of cleaning. The manager explained this was planned, as the home had booked the use of an industrial carpet cleaner, which is shared by a few homes in the organisation. The external painting of the home was commencing this month. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 16 Also planned for the near future were alterations to the entrance of the home, to create a designated smoking room, this will ensure visitors to the home no longer have to walk through a smoky environment. On the whole the home was clean and hygienic and free from hazards. Specialist equipment and adaptations were in place, with the home making appropriate referrals for advice and equipment when needs arise. The laundry was well ordered and fitted with suitable equipment. Based on discussions with residents and from examining feedback from the resident’s survey, laundry going missing or being given other people’s clothes, is an ongoing issue. The inspector acknowledged staff shortages will have impacted on this situation and agreed with the manager that laundry routines should be reviewed, to try and alleviate the problems. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 17 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. For some time the home has been operating with insufficient staff, requiring existing staff to work additional shifts, this situation should improve with the recent appointments. The home has a committed staff team, who are suitably trained. EVIDENCE: On the day of the inspection there were still several vacant positions on the staff rota, however recent recruitment had been successful and all the vacancies had been appointed to. Currently all the necessary recruitment checks were being completed, prior to inducting the new staff to the home. The inspector met with two night staff who had finished their shift, in addition to formally interviewing three care staff and meeting other staff during the course of the inspection. On the whole staff spoke positively about the supervisory and management support they received and were confident their views were listened to and acted upon. The content of the staff meeting minutes confirmed this with a wide range of issues discussed and staff able to raise issues affecting them. The involvement of night staff in training and staff meetings was discussed with the manager. She acknowledged the difficulties of ensuring night staff were being treated fairly and explained how she will work a late shift to get contact with them. In addition she described plans for a dedicated night shift staff meeting for all night staff, which would be made possible by covering the night shift with relief staff. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 18 The home has recently developed a training matrix, to monitor and record all the training activity undertaken by staff, ensuring it is in line with relevant guidance. On the whole staff spoken to said they were receiving appropriate training and training requests were acknowledged. A recent medication training course had been well received, with staff now feeling “more confident in their role”. Staff under 25 were able to access NVQ training via an independent training provider, with the organisation providing NVQ training for all other staff. All necessary checks and disclosures were in place for the existing staff group. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 19 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): 32, 33, 34, 35, 36, 38. The manager of the home provides clear leadership, with the residents and staff feeling well supported. EVIDENCE: The manager has a good rapport with residents and staff alike. It was evident there was a mutual respect, with residents and staff feeling valued and well supported. The manager provides good leadership and was very approachable and open to ideas. Through resident and staff meetings, in addition to ongoing consultation on both a formal and informal basis, the manager was aware of current issues requiring action. Quality assurance questionnaires had recently been circulated to residents, staff and other interested parties and were in the process of being collated, prior to the results being published and fedback to all participants. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 20 Based on discussions with staff and examination of some staff files, it was evident staff were receiving good levels of supervision and support as required. Annual appraisals had also been completed for all staff, with the manager formally supervising the supervisors and the supervisors taking responsibility for supervising care staff. On the whole the home was free from hazards, however a bottle of cleaning screen was not securely stored under a sink on one of the units. West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 21 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 X 3 X X 3 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 X 3 3 3 3 3 X 2 West Point House DS0000035574.V253523.R01.S.doc Version 5.0 Page 22 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 38 Regulation 13(4) a Requirement All CCSHH substances must be securely stored at all times. Timescale for action 05/10/05 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 4 Refer to Standard 7 7 7 12 Good Practice Recommendations It is recommended care plans are reviewed and updated in line with the monthly assessment and signed by residents or their representatives. Care plans, particularly for people with dementia, should incorporate a social history and information relating to individual interests and hobbies. Particularly for people with speech difficulties, care plans should identify individual communication needs and preferences. It is recommended the home continues to consult with residents regarding activities and interests, keeping the situation under review and ensuring an appropriate range of activities are provided. It is recommended independence is promoted/encouraged at mealtimes, by making food more accessible to residents, enabling them to serve themselves if they are able. DS0000035574.V253523.R01.S.doc Version 5.0 Page 23 5 14 West Point House 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. 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