Inspection on 27/06/06 for Westcliff Lodge

This inspection was carried out on 27th June 2006.

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

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

Other inspections for this house

Westcliff Lodge 21/06/07

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 Pauline Marshall Key Unannounced Inspection 27th June 2006 9:15 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.V293488.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.V293488.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.V293488.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 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, taxi’s, 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.V293488.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place over two visits the first on the 8th June 2006 lasted for two hours and ten minutes, the second on 27th June 2006 lasted for four hours and fifty minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents, staff, and a visiting relative. As part of this inspection surveys were sent to six residents, two relatives and two General Practitioners to obtain their views on the service the home provides. Three residents surveys were returned only and all were positive in their comments, saying how residents were well cared for, happy and content and one comment was that the home is “just great”. No other survey forms have been returned to date. Twenty-six of the thirty-eight standards were inspected. What the service does well: What has improved since the last inspection? The home has re-carpeted several bedrooms and the stairs; there is new furniture in some of the bedrooms and in the lounge. The home has purchased a fish tank for the residents to enjoy, and this is located in the front lounge. The car plans have improved and give staff clear instructions. The home now employs a designated activities worker for one and a half hour each weekday afternoon. There are additional hours for a teatime cook. PRN (as and when medication) protocols are now in place and the home has completed its report on the review of the quality of care it provides. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 Page 6 What they could do better: 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.V293488.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.V293488.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, 2, 3, 5, 6 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home carries out a thorough pre-admission assessment of needs and provides prospective residents with sufficient information to enable them to make an informed choice. The home offers prospective residents the opportunity for trial visits prior to admission. Each resident is provided with a contract. EVIDENCE: A copy of the homes Statement of Purpose and Service User Guide is provided to all prospective residents. All current residents have a copy of these documents in their individual bedrooms. Relatives spoken with said they were very happy with the information provided to them before the admission took place. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 Page 9 Each resident has a completed contract that states his or her terms and conditions of residency that is signed by both the home and the resident or their representative. The homes manager carries out a full pre-admission assessment prior to admission, care files examined evidenced this. Wherever possible prospective residents and their relatives are encouraged to visit the home prior to admission to ensure that they are satisfied that the home can meet their needs. Westcliff Lodge does not provide intermediate care. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 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, 9, 10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The homes care plans contain the information required to meet the residents’ needs. Health care needs are fully met, however the homes record keeping method of Doctor’s visits needs reviewing. There is a medication policy, which is due for review. Residents are treated with respect and their dignity and privacy is upheld. EVIDENCE: The care planning system has been developed since the last inspection and now gives greater clarity of information for staff to meet residents’ needs. Care files examined showed clear evidence of all health care appointments. The home maintains records of General Practitioners visits in their doctors’ book; this information is confidential and should be store on the individual residents care file. An anomaly was noted regarding communication issues with regards to a resident’s health. This is completely out of character for the home as there is Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 Page 11 evidence that communication is normally effective, therefore the Responsible Individual will be undertaking a full investigation into the matter. The home has a medication policy dated August 2003; the manager said that all policies were in the process of being reviewed. The home does not have a copy of the Royal Pharmaceutical Society of Great Britain guidelines for the Administration of Medication in Care Homes, the manager said that the owner would obtain a copy from the Internet and that it would be shared with staff. All PRN (as and when) protocols were in place. Residents spoken with said that staff treated them well, with respect and always observed their privacy. Staff interaction with residents observed on the day of the inspection confirmed this. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents experience a lifestyle that matches their needs, they are encouraged to maintain contact with family and friends and have as much choice and control over their lives as possible. Residents receive a wholesome appealing balanced diet in spacious pleasing surroundings. EVIDENCE: The home now employs a designated activities worker for one and a half hour’s weekday afternoons. The activities worker is also employed by the home in the position of cook. Residents said they enjoy working with the activities worker and that they are offered a range of activities, including cards, puzzles, bingo, ball games, fish & chip suppers, cheese and wine evenings and barbeques in the nicer weather. In addition to these activities an entertainer visits the home six times a year. The home encourages its residents to keep in contact with family, friends and the local community if they wish; visitors are welcome at the home at any time, and this was confirmed by a visiting relative. Trips to the local theatre are arranged at the residents’ request. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 Page 13 The home holds residents meetings, some informal and some more formal where notes of the meetings are kept. Each care file has a section for relatives and residents to complete to enable them to state their views. As part of the admission process, the homes uses a “getting to know you” form, this asks each resident for basic information about them that assists the care staff to meet their needs. The home has two sittings at mealtimes, the first sitting require staff assistance to eat their meal. The menu offered a choice of salad as an alternative to the main meal. The manager said that she was in the process of reviewing the menus and will ensure there is another hot meal option available. The home now employs a teatime cook, residents spoken with said “the food is lovely”. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 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, 18 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Complaints are acted upon swiftly and all issues are taken seriously by the home. Staff are well trained and residents are protected from abuse. EVIDENCE: The home has a complaints policy and procedure that is in the process of being reviewed. There have been no complaints since the last inspection. There is a policy and procedure for dealing with suspected abuse and it works within the Southend Borough Council Adult Protection Procedure. All staff have received training on the protection of vulnerable adults and staff spoken with showed a good knowledge of the actions they should take if they suspected abuse. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 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, 24, 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents live in a safe well-maintained environment with their own personal possessions around them and the home is clean, pleasant and hygienic. EVIDENCE: The home has re-carpeted several bedrooms and the stairs; there is new furniture in some of the bedrooms and in the lounge. The home has purchased a fish tank for the residents to enjoy, and this is located in the front lounge. The homes environmental health inspection was carried out on 26th January 2006 and all matters requiring attention have been addressed. Each bedroom is individually decorated and residents are encouraged to have their say in the colour schemes chosen. Bedrooms have many personal possessions in them and are clean and comfortable. Residents spoken with confirmed that rooms are nice and homely. The home was clean and pleasant. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Staff are well trained, competent and supplied in sufficient quantities to meet residents needs. The homes recruitment practice supports and protects residents. EVIDENCE: The homes rota evidenced that there is always two care workers plus a senior carer on duty during the day and that the cook and domestic staff are in addition to this on weekdays. The manager lives at Westcliff Lodge and is on call when not on duty and covers the sleep-in duties most nights. One carer works throughout the night and will contact the on-call officer if necessary. The owner and manager said that they have been looking at the options for NVQ training for the staff team and will be enrolling staff for this training at the South East Essex College in September 2006. Staff spoken with confirmed that there were good training opportunities offered and that they were looking forward to commencing their NVQ studies. The home has good recruitment policies and practice; all the staff files examined contained the relevant documents. There is a good induction programme that was evidenced on staff files and staff spoken with confirmed that induction and training was very good. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home is well managed and run in the best interests of the residents and their financial interests are safeguarded, however the home needs to review its practices on handling residents personal allowances.. The health, safety and welfare of the residents is promoted and protected. EVIDENCE: The manager has worked at the home since 1991 and has managed it for the past nine years; she has achieved the City & Guilds Advanced Management for Care qualification and regularly updates her knowledge by undertaking training courses on service specific subjects. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 Page 18 The home has a quality assurance system that includes consulting residents, their relatives and visiting health care professionals. Surveys were undertaken in March 2006 and the report and its action plan was published and shared with stakeholders in May 2006. A further quality assurance survey is planned to take place in February 2007. Three residents cash records were inspected and were all found to be incorrect. The manager said that money had been loaned to residents from other resident’s funds due to them having no cash available and requiring personal items. This practice must cease and residents’ personal allowances must never be used for other residents and appropriate records and receipts must be kept. The owner is responsible for paying all invoices and stores all business records at her home. The home has adequate insurance cover and all safety certificates and fire drills were up to date. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 Page 19 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 Page 20 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 OP28 OP35 Good Practice Recommendations A minimum of 50 trained members of care staff to achieve NVQ Level 2 or equivalent by 2005. Residents’ money must not be used for others and appropriate records and receipts must be kept. Westcliff Lodge DS0000015483.V293488.R01.S.doc Version 5.1 Page 21 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. 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