Inspection on 10/02/06 for Westcliff Lodge

This inspection was carried out on 10th February 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.

Other inspections for this house

Westcliff Lodge 21/06/07

Westcliff Lodge 27/06/06

Westcliff Lodge 31/08/05

Westcliff Lodge 17/01/05

Westcliff Lodge 24/09/04

Westcliff Lodge 23/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Westcliff Lodge 118/120 Crowstone Road Westcliff On Sea Essex SS0 8LQ Lead Inspector Pauline Marshall Unannounced Inspection 10th February 2006 9:10 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 Westcliff Lodge DS0000015483.V282734.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. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westcliff Lodge Address 118/120 Crowstone Road Westcliff On Sea Essex SS0 8LQ 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) 01702 354718 01702 354718 Westcliff Lodge Limited Mrs Jacqueline Pinnock Care Home 20 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (20) of places Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: The home may accommodate up to twenty older people of either sex, three of whom may fall within the category of Dementia. Date of last inspection 31st August 2005 Brief Description of the Service: Westcliff Lodge is situated in a residential area of Westcliff on Sea. It is located within reasonable walking distance of all local community services and facilities. Westcliff main line railway station and the seafront are close by and the resort of Southend on Sea is easily available. Westcliff Lodge is registered to provide care for twenty elderly people, no more than three of who may be suffering from dementia. The home provides sixteen single and two double rooms. All bedrooms, except for one single, have en-suite facilities. There are two lounges and a conservatory, parking to the front, and a rear garden for residents to use. The accommodation is on two floors; a passenger lift provides access. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection that lasted 4 hours and 15 minutes. The inspection process consisted of discussions with the manager, staff and residents; a tour of the premises and examination of a random selection of resident and staff files. The process also included a check of all relevant equipment documentation and electrical and gas safety in addition to the homes fire, water and fridge and freezer temperature records. What the service does well: What has improved since the last inspection? What they could do better: NVQ training needs to be organised to enable care staff to meet the National Minimum Standards. PRN (as and when) protocols should be in place to ensure that medication instructions are followed exactly. A report on the outcome of the quality assurance consultation should be made available to residents and their relatives in addition to a copy being sent to the CSCI Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 6 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. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 The home has a good admissions process and provides clear information to prospective residents. Visits to the home by prospective residents and their families are encouraged to enable them to assess the quality and suitability of the home. EVIDENCE: The Responsible Individual is currently reviewing the Statement of Purpose and the residents’ information pack. The manager carries out a full pre-admission assessment to ensure that the home can meet the prospective residents needs. The care file of a resident that was admitted the day before the inspection contained a pre-admission assessment and risk assessment and care plan, which the manger stated will be developed further as more information is obtained. Visits by prospective residents and their families are encouraged prior to admission. This has not been always possible if the resident is admitted directly from the hospital. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, The health, personal and social care needs are set out in the care plan. There are clear policies and procedures on administration of medication and staff are trained, however all as and when medication should have clear protocols in place. EVIDENCE: A random sample of residents files contained a comprehensive pre-admission assessment that informed the care plan; which included risk assessments on environmental and moving and handling risks. The manager has began the development of the care files to ensure greater clarity of information for staff to meet residents’ needs and to improve the daily records as discussed at the last inspection. Administration of Medication is the responsibility of senior care staff; the manager said that she undertakes regular audits of medication system. All medicine administration records were completed correctly and there was a list of names with signature and initials of staff that administer medicines. There are clear policies and procedures on administration of medication and staff are trained. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 10 There was PRN (as and when required) medication with the instructions to take as directed. There were no protocols in place for the use of these medicines. All as and when medication must have a clear protocol on its use. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 The home encourages residents to participate in a wide range of activities. The dining area is pleasing. Menus do not offer a choice of meals. EVIDENCE: There is an activities calendar displayed on the wall outside the dining area, it offers a range of daily activities for residents to participate in. Residents often decline to take part and when they do so this is recorded in their care file. Residents spoken with said that they enjoyed bingo, television and liked reading. Staff were seen to interact well with residents and encouraged them to participate. The manager continues to investigate relevant activities through various professional organisations. There are two sittings at mealtimes, the first sitting require staff assistance to eat their meal. The menu did not offer a choice, however the manager said that residents ask if they want an alternative; the cook said that he is in the process of updating the menu and will reflect the choices. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents are protected from abuse. EVIDENCE: The home has robust procedures in place for dealing with adult abuse and these procedures are in line with Southend Adult Protection Procedure. There is a policy on handling finances and receiving gifts and legacies. All staff have attended training for the protection of vulnerable adults. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 26 Residents have specialist equipment to maximise their independence. The home is clean, pleasant and hygienic. EVIDENCE: Most residents bring their own walking aids and wheelchairs on admission to the home, however some are purchased by a family member; the manager said that should any further equipment be required, she would refer to the Occupational Therapist team for a full assessment. The home has two hoists that are regularly serviced and grab rails throughout the building. There is a passenger lift that some residents use independently. All bedrooms were tidy and en-suites clean and odour free; the communal areas were clean, hygienic and pleasant. The home has a redecoration programme and carries out a daily audit for repairs and renewals, it employs a handyman that carries out any emergency tasks at the time they are identified. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 Staff are not suitably qualified to NVQ level 2 or equivalent. Recruitment procedures and practices are generally good, however evidence of workers fitness must be obtained. EVIDENCE: Three staff are registered with Mulberry House for induction training. No staff have enrolled for NVQ training; one carer spoken with said she could not afford the fees. The manager will investigate if any grants are available to assist the home to meet this standard. A random sample of staff files was inspected and contained supervision notes and all elements of Schedule two apart from evidence that the person is physically and mentally fit. Evidence that an employee is physically and mentally fit to do the work must be kept on the staff file. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 The home is run in the best interests of the resident. The accounting and financial procedures of the home protect the residents. EVIDENCE: There is a quality assurance policy and system in place that consults with residents, staff, relatives and other professionals. The Responsible Individual will be collating the information collected from the consultation and will publish a report and send a copy to the CSCI when completed. The home has adequate insurance cover that includes business interruption. The Responsible Individual keeps all transactions records and invoices at her home. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 16 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X 3 X X X 3 STAFFING Standard No Score 27 X 28 1 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 X X X X Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 17 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. Standard Regulation Requirement Timescale for action 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 OP7 OP9 OP12 OP28 Good Practice Recommendations The home should continue to develop its care planning systems. The home should ensure that there are protocols in place for PRN (as and when) medication. The home should continue to develop the activities for its service users. A minimum of 50 trained members of care staff to achieve NVQ Level 2 or equivalent by 2005. Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Westcliff Lodge DS0000015483.V282734.R01.S.doc Version 5.1 Page 19 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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