Inspection on 21/06/07 for Westcliff Lodge

This inspection was carried out on 21st June 2007.

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

Westcliff Lodge 27/06/06

Westcliff Lodge 10/02/06

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 Sarah Hannington Unannounced Inspection 21st June 2007 10:30 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 Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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.V341270.R04.S.doc Version 5.2 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 Ms Stephanie Margaret Allardyce 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.V341270.R04.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 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 of the building, and a rear garden for residents use. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £330.00 to £510.00 per week and there are additional charges for hairdressing, chiropodist, taxis, toiletries, magazines and newspapers, outside social trips such as theatre and shopping and any personal hygiene items. The accommodation is on two floors; a passenger lift provides access. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit Inspection was unannounced and took four and a half hours to complete. The manager was present through out this process. This inspection looked at all the key standards and requirements from the last inspection. Four relatives, seven residents and three staff were spoken with as part of this process. What the service does well: Quality assurance within the home is well thought out to a very high standard. The manager collates the responses and feeds back the results within resident and staff meetings. The results of this survey are also made into a document and are available to all interested parties. Some of the issues raised within this inspection report concur with the results of the home’s own quality assurance monitoring surveys. As a result the manager is already in the process of addressing some of these issues within her action plan for the home. This is good practice. The home and staff are warm friendly and relaxed. The home itself was clean and homely. Staff were seen to be dedicated in ensuring residents retained skills and independence. The home ensures that diversity and equality is also part of the day-to-day running of the home, individual’s dietary and religious beliefs were observed to have been catered for. All residents have a GP of their choice. A new staff key working system has been implemented. Residents’ meetings were held every six months and are informative, giving information such as, new staff employed, role of the key worker, food and menu’s and Quality assurance results. Staff support including supervisions, meetings and training were regular and to a good standard. The redecoration and maintenance plan of the home was very comprehensive and thorough. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home needs to develop ways of evidencing activities carried out by recording things such as choices, activities tried, given, offered and maybe refused. The signature, dates and that consultation has gone ahead with residents and families needs to be in place. The home needs to develop proper signage for residents with dementia. A refresher course or meeting for some staff regarding the administration of medication including the guidance from the ‘Royal pharmaceutical guidelines.’ needs to be carried out. The manager needs to develop staff awareness around providing a relaxed and unrushed mealtime for residents. Additionally recording systems around fluid intake and meals eaten need to be developed in terms of being able to track and evidence what is ‘actually’ consumed. Unpleasant odours in two of the resident’s rooms need to be resolved. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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 Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good standard of pre-admission policy and procedures. EVIDENCE: Relatives and residents spoken with confirmed that visits and information such as the Statement of Purpose and Service User Guide was provided prior to admission. This documentation supported them to make a decision that the home could meet their relative’s requirements. Assessments are to a good standard. No intermediate care is being provided. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good information and risk assessments in place. Care plans may need further development. Medication is organised to a good standard. All staff administering medication need to be practising to the required safety standards according to the ‘Royal pharmaceutical guidelines’. A good standard of care is being implemented within Westcliff Lodge. EVIDENCE: Each resident has a ‘Care Folder’ folder that contains useful and detailed information. Information essentially is to a good standard including assessments and evidences that individual’s health care needs are fully met. A ‘snapshot’ version including photographs of residents for quick reference would benefit existing staff and be useful to any agency or new staff that may be acquired or needed in the future. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 Page 11 Care plans could highlight resident routines in the morning, lunchtime, their activities, nighttime preferences, district nurse visits or anything else, which is ‘specifically’ important to them and should include how they would like staff to support them. Additionally the present care ‘folder’ provides no evidence either by signature or comments to show that the resident has agreed consultation of care package or they’re representative. A Monitored medication dosage system is in place for each resident. Medication is stored in a lockable cabinet. All MAR record sheets had been correctly recorded, signed for and there were no gaps in vital information needed. The administration records are maintained in accordance with agreed procedures and the royal pharmaceutical legislation. Evidence of documentation, training, and no incidents around medication issues or practice would suggest that medication is kept to a strict protocol and is maintained consistently to a good standard. However observation of staff administering medication revealed that staff might benefit from a refresher course in the safe handling and storage of medications whilst administering medication to residents. This is in direct relation to a member of staff leaving medication packs on top of an unattended medication trolley whilst they administered medication to a resident behind a closed bedroom door. Residents spoken with felt that they were treated with dignity and respect. From observation staff were seen to be caring, listening and interaction with residents was good. Evidence of documentation backed up good practice in these areas. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes manager is further developing activities. Relative contact is encouraged and creative ideas are being explored. The choice of meals is good. EVIDENCE: The manager currently is finding new ways of introducing activities within the home and within the community. This has been addressed as a result from the quality assurance surveys sent out by the home and responses received. Some of the present in house activities include families. This allows families, friends, residents and staff to interact and generally get to know each other better. Documentation around activities should be developed in terms of evidencing that consultation has been carried out and to clearly record the outcomes. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 Page 13 Some of the friends and families of residents live abroad or some distance away from the home, so the manager has set up E-mail and an Internet site that all parties can access. Additionally residents can be provided with their own phone lines in their private rooms if wanted. All relatives spoken with said they felt welcomed into the home, there were no restrictions and that staff were always available for a chat if need be. The home ensures that diversity and equality is also part of the day-to-day running of the home. Individual’s dietary and religious beliefs were observed to have been catered for. All residents have a GP of their choice. Residents meetings were held every six months. A new key worker system has been recently introduced. In general residents and relatives spoken with felt that the meals provided reflected their choice of foods, met cultural and religious requirements and were of good quality. Lunchtime was observed and the food smelt good, looked nice and was home cooked. If a meal did not appeal to one of the residents then an alternative meal would be provided. However observation during the lunchtime meal revealed that there was very little interaction between staff and residents. Staff were not sitting down and chatting with residents or leaving them to have unrushed meals. Staff were observed to be standing and waiting to clear up plates, which were taken away as soon as a resident finished. It maybe that staff may regard this time as being a practical duty - to carry out tasks. However although this time of day is obviously a busy part of the day, a relaxed unrushed interactive environment at mealtimes should be further developed. During the inspection visitors and residents were asked about the quantity and frequency of food and drinks. There was a mixed response. Some residents and relatives felt the amount of food and drink was plentiful and others felt that the suppertime meal was too light until breakfast time. Again some felt that hot or cold drinks were not readily available and others felt that what they were offered or asked for was sufficient. Conflicting opinions amongst the residents and relatives in this area were discussed with the manager during the inspection process. It is noted that this issue had been discussed within the residents meeting and has already been identified by the manager. Developing documentation such as a tracking system which records fluids, food offered and consumed would evidence that there is sufficient provision for each resident’s needs and that individual consultation over choice and preferences had been carried out. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 Page 14 This would also evidence that the home is working in a proactive way rather than reactive in terms of being able to eliminate factors that may contribute to issues such as pressure sores, infections, falls and weigh loss/gain. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good policy and procedures around complaints. Staff are able to ensure the safety of residents. EVIDENCE: There have been no complaints made to the home or any issues reported to CSCI since the last inspection. Both relatives and residents said that if they needed to they would know how to make a formal complaint and who to raise this with. The home’s quality assurance surveys were looked at as part of the inspection process. A survey returned by a resident stated ‘I am very impressed by the way my concerns have been received sympathetically and effective action has been taken’. The home has received a number of compliments. All staff have had safeguarding training. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home environment provides a clean, comfortable and safe environment in which to live in. The home may want to develop proper signage for those residents with dementia. EVIDENCE: Overall the home presents no health and safety issues. The environment was homely, comfortable and practical for the use of residents at Westcliff Lodge. On the day of inspection the home was observed to be clean, tidy and odour free in most areas. However in two of the resident’s rooms there was an odour control issue that needs resolving. All residents’ bedrooms were personalised and comfortable. Some of the residents at Westcliff Lodge have dementia and the home is decorated in similar shades that may not support residents in recognition of Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 Page 17 different areas. The manager may want to look into development of signage. This may support residents in retaining some independence around the home and to recognise familiar routes, such as identify their own bedrooms and other different parts of the home. The garden provides a pleasant area for residents to use and has recently been refurbished. New kitchen equipment and dinning room furniture have been acquired. The conservatory has had blinds installed and new air coolers put into place. In the near future a luxury bathroom is being created and new parker bath in another bathroom is being purchased and installed. The redecoration and maintenance plan of the home was very comprehensive. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supplies sufficient numbers of staff on duty with good experience and skills that are able to meet the needs of residents. Recruitment is to a good standard. EVIDENCE: The home’s induction pack is to a good standard. Staff have been enrolled on NVQ training since the last inspection. Staff are also supported by the means of supervisions, meetings and training. The rota reflects that there is sufficient well-trained staff to cover and lead each shift. Staff spoken with evidenced that they were competent, confident in their roles and able to give a good standard of care to the residents. Paperwork for staff recruitment is to a good standard. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is good at promoting and protecting the health and safety of the residents at westcliff Lodge. Looking at paperwork and through discussion with individual residents and relatives evidenced that good teamwork is in place and clear leadership skills from the manager are present. EVIDENCE: There has been a new manager in post for the last four months and she has implemented many new efficient ways of recording information and introducing new systems that directly benefit the residents. The manager evidenced that she understood her role well and that she had a good understanding of residents’ needs and support needs of the staff. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 Page 20 The current manager is NVQ4 and RMA trained. She is also an NVQ assessor. Quality assurance within the home is to a very high standard. The manager collates the responses and feeds this back to residents and staff. It is available to all interested parties. Many of the issues raised in the inspection were raised in surveys sent out and the manager is in the process of addressing these within her action plan drawn from these results. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 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 X 4 X 3 X X 3 Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 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. 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 Refer to Standard OP7 OP9 Good Practice Recommendations The staff team should ensure that documents entitled care plans include residents and their representative’s views and are signed and dated to evidence consultation. All staff that administer medication should practice within the expected safety pharmaceutical guidelines. This is in relation to staff leaving medication packs on top of the unattended trolley, whilst other medication is administered to an individual behind a closed door, to ensure resident safety. Suitable arrangements should be made for all residents to receive a varied programme of in house and community based activities and that this is recorded appropriately. The staff team should ensure that mealtimes are eaten unhurried and in a relaxed atmosphere. This is in relation to staff sitting down with residents at mealtimes rather than standing in front of them waiting to clear plates whilst other residents are still eating their meals. DS0000015483.V341270.R04.S.doc Version 5.2 Page 23 3 4 OP12 OP15 Westcliff Lodge 5 OP22 6 OP26 Consideration should be given to the design and layout of the home regarding the use of appropriate signage in order to meet the assessed needs of residents with Dementia. Unpleasant odours in private bedrooms need to be resolved to improve the environment for a small number of residents. Westcliff Lodge DS0000015483.V341270.R04.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V341270.R04.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!