Inspection on 11/05/05 for Westleigh Lodge

This inspection was carried out on 11th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Westleigh Lodge 17/11/08

Westleigh Lodge 26/06/08

Westleigh Lodge 01/11/07

Westleigh Lodge 25/10/06

Westleigh Lodge 15/05/06

Westleigh Lodge 05/12/05

Westleigh Lodge 04/10/04

Westleigh Lodge 15/04/04

Westleigh Lodge 21/11/03

Westleigh Lodge 27/05/03

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

CARE HOMES FOR OLDER PEOPLE WESTLEIGH LODGE Nel Pan Lane Leigh Lancashire WN7 5JT Lead Inspector Judith Stanley Announced 11 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westleigh Lodge Address Nel Pan Lane Leigh Lancashire WN7 5JT 01942 262521 01942 674783 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Healthcare Services Ltd CRH Care Home with Nursing 48 Category(ies) of DE Dementia 48 registration, with number of places WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the maximum registered number 48 there can be up to:48 adults with Dementia (DE) 2. The service should at all times employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection Date of last inspection 4 October 2004 Brief Description of the Service: Westleigh Lodge is a purpose built two storey nursing home that offers care for up to forty eight people over the age of 65 years, of either sex who are suffering with dementia. The Home is owned by Southern Cross Health Care and is situated on the outskirts of Leigh town centre. The Home is within easy reach of local shops and facilities and is well served by public transport. There is a car park to the front of the Home. Accomodation is provided on the ground and first floor, both floors have a communal lounge and dining rooms. There is a passenger lift to all floors, the third floor is the homes kitchen, laundry and staff room. All residents have a single room with en suite facilities. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and was undertaken over a five-hour period. The first part of the morning was spent talking with the acting manager, discussing the general running of the Home and training for staff. Records, care plans, accidents reports and other records were looked at. The remainder of the time was spent of a tour of the Home, speaking with staff and relatives. Due to the high number of residents at the Home in the advanced stages of dementia it was very difficult to ask residents views of the services provided, therefore the Inspector spent some considerable time watching how staff spoke with residents and their general care practices and how the residents responded to the staff. In order to obtain further information about the Home the acting manager, the administrator, cleaners, the chiropodist, 6 members of staff and 3 relatives were spoken with. Comment cards were given to relatives of which 3 have been returned, 2 residents and 2 GPs have also completed comment cards. What the service does well: The acting manager and staff provide a good standard of care for residents. Relatives spoken with said that good support for the families of residents is offered and that the way the staff tell relatives about what is going on is good. One relative praised the staff saying “ I am pleased with the care my wife receives. The staff are always ready to listen to you when you have a question to ask. They are kind, considerate and pleasant and I am grateful for the comfort they give my wife”. Another relative made comment that, “she very pleased with the Home and care and friendliness of the staff”. Several of the staff had worked at the Home for some time and staff said they worked well as a team and got on well together. Residents and staff were comfortable with each other and staff knew a lot about what the residents in their care needed. The acting manager makes sure that residents are comfortable and cared for properly, as well as making sure that staff can meet the individual’s care needs. The information recorded in the care plans is clear and gives good information about caring for the individual. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 2. Standard 6 does not apply as Westleigh Lodge does not offer an immediate care service. The Home’s statement of purpose and service user guide does not provide sufficient information in a suitable format for residents or prospective residents to make an informed decision about coming to live at the Home. Terms and conditions of residence/contracts were not in place for all residents to ensure that relatives and residents were clear about their rights. EVIDENCE: The service users information guide is available to all residents and relatives. It contains a description of the services and facilities provided. The Home is registered to care for people with dementia. The information needs to be made available for residents in a way that is easy to follow. This could be through pictures or a video that shows the bedrooms, the bathrooms, who the staff are and what goes on in the Home in a daily basis. Details of the staff qualifications and their experience and training for caring with dementia are included in the guide. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 9 The acting manager confirmed that details of terms and conditions were not available for all residents. This mainly affects residents who are privately funded. The acting manager must ensure that all residents, regardless of how their care is purchased are issued with a written statement of terms and conditions (contract) at the point of moving into the Home in line with the National Minimum Standards for Older People (NMS 2). WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 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 standard(s) 7,8 &10 In the main, the care plans were detailed, up to date and reflected the care needed. The health needs of the residents are well met, with evidence of good multi disciplinary working taking place as required. EVIDENCE: Individual care plans were available for inspection. Examination of four files indicated that all aspects of resident’s health and personal care needs are planned for. All four files inspected were found to be up to date and had been reviewed on a monthly basis and any changes to the planned care had been documented. Discussion with two relatives indicated that they had been involved in the initial drawing up of the care plan and were aware that they could read the care plan if they wanted. There was clear evidence of access to community health services such as residents GP and Chiropody. One relative has made comment about the lack of dental treatment for her relative. This was discussed with the acting manager who confirmed she is aware of the situation and has tried on numerous occasions, and is still trying to find a dentist that will take on new patients. Feedback from two GPs that regularly visit the Home indicate that WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 11 they are satisfied with the overall care provided to service users within the Home. Detailed risk assessments were in place in each of the files inspected. They covered areas such as nutrition, pressure areas, moving and handling and falls. Staff at the Home were observed treating residents with privacy and dignity and speaking to residents in a natural and respectful manner. Relatives also expressed satisfaction in this area. Some feedback indicated that they can visit their relative in private and care and attention is given when staff are providing personal care and assistance to residents. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 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 standard(s) 12 & 15 The provision for social activities is lacking and does not satisfy the needs of the residents. The meals are good offering both choice and variety and catering for special dietary needs. EVIDENCE: A social activities coordinator is employed, however, the manager confirmed that she has taken on a more caring role, as it was very difficult for her to plan and deliver a suitable range of activities for residents with dementia. It was discussed with the acting manager that residents with dementia respond better to an organised day. It would help to stimulate them and build on the abilities they still retain. The activity coordinator and other staff would benefit from some training in planning and delivering activities; these could include music and movement, singing, dusting, laying the tables and arts and crafts. In order to develop present provision to meet all the needs of the residents, including those who are being nursed in bed, further activities and individual time spent with residents should be introduced. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 13 Lunch was observed being served to residents on both floors. Lunch consisted of stewed meat and dumplings, creamed potatoes, carrots and sprouts. A pureed diet was served in an appealing manner to residents with portions being individual blended. A choice was available, however it appeared to be chosen by staff that had an awareness of residents likes and dislikes rather than the residents own choice. Some consideration is needed surrounding meals times. Although the home was staffed with the minimum staffing levels, staff appeared to be finding it difficult to assist all the residents that needed help. Some residents were being fed in their rooms and others in the corridor, which was their choice; the manager confirmed these residents did not like to go in to the dining room. Some residents were left to their get on with their lunch on their own. Staff had not the time to spend with residents and assist them in an unhurried manner. The meal was not relaxed and the upstairs dining room is not a congenial setting for residents to dine in. Due to the high levels of dementia within the Home it was difficult to ascertain residents views of the quality of the food. Observation indicated that some residents appeared to be enjoying their lunch whilst others seemed uninterested. One relative spoken with who visited the Home everyday said that the meals served were good and a wide choice was available. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 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 standard(s) 16 & 18 Systems were in place with regard the investigation of complaints and adult protection issues ensuring that residents are listened to and protected. EVIDENCE: The Home has complaints procedure that is advertised within the Home. Due the high levels of dementia residents would find it difficult to make a complaint. Two relatives spoken with were aware of the complaints procedure and felt confident that the manager would act promptly to any areas of concern raised. One complaint has been made to the CSCI over the last year alleging poor care practice. The complaint was not upheld. Whilst staff had some knowledge regard the protection of vulnerable adults, all staff should receive training in this area. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 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 standard(s) 19,24, 25 & 26 The standard of the decoration and furnishing is generally good, providing residents with a comfortable and homely environment. Infection control procedures are good, making this a clean environment for residents. EVIDENCE: From a tour of the building, it was seen that the premises were generally well maintained to a satisfactory standard, both inside and out. There was some evidence of redecoration and some renewal of fabrics and furnishings. The acting manager had identified the dining room on the first floor is in need of attention and new floor covering is needed. It was also noted that some chairs in the downstairs lounge needed replacing, some were old or heavily stained. The premises were clean to a satisfactory standard and free from offensive odours. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 16 Bedrooms were observed to be comfortable, clean and tidy with evidence of personal touches. Systems were in place to control the spread of infection. Staff were knowledgeable about infection control procedure, and were seen washing hands between tasks and using appropriate protective aprons and gloves. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 Staff morale is good, with low levels of turnover of staff. This ensures that residents are provided with care by people they know and are familiar with. Sufficient staffing hours were provided to meet the agreed level, however this needs to be reviewed due to residents high dependency levels. Staff need to learn new skills to successfully meet the more complex needs of residents. EVIDENCE: A rota is kept showing, which staff are on duty and at what time, shifts are covered with the minimum numbers of staff as agreed on the staffing notice. It was observed that staff, although they appeared kind and caring had little time to spend with the residents. The staffing levels should be reassessed to ensure that resident’s needs are fully met with extra staff on duty at peak periods of the day for example mealtimes. Two relatives returned comment cards have indicated that they feel the Home is often understaffed especially at weekends. Three relatives spoken with offered praise for the acting manager and staff, one said, “ all the staff are very kind and caring, I am very pleased with the care provided”. Not all staff have received up to date mandatory training for example moving and handling, first aid and the protection of vulnerable adults. All staff should receive training in caring for people with dementia to ensure that they have the knowledge they need to deliver the appropriate care. Two members of WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 18 staff spoken with confirmed that further training is required especially around caring for people with dementia. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35 & 38 The acting manager is suitably qualified and experienced and has a good understanding of the areas in which the Home needs to improve. A satisfactory accounting system was in place, which protected resident’s interests. Not all staff have received relevant health and safety training, which could put residents at potential risk EVIDENCE: The Home has been without a registered manager for some considerable time. The acting manager has still to submit to the CSCI an application to be the registered manager. The acting manager has a good understanding of the areas in which the Home still needs to improve with regard to redecoration and training. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 20 The Home had a satisfactory accounting system in place. The administrator could determine exactly how much money the Home was holding for each person and how the money was being spent. Receipts for financial transactions were kept. In the main, safety issues were satisfactory with regular checks of equipment being undertaken. All accidents and incidents were being correctly recorded and reported. From discussion with the acting manager and checking staffing training it was clear that mandatory health and safety training had not been implemented for some staff and had not been regularly updated. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x 3 3 3 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x 3 x x 2 WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation Sch 1 Reg 4(1)(c ) 5 Sch 1 Reg 4 (1)( c ) 23 & 18 Requirement The format of the service user guide needs further review in order to meet the standard required All residents to be issued with a contract or statement of terms and conditions Suitable arrangements for residents to engage in activities, hobbies and leisure interests. A choice of meals to be offered in a format to suit the capacities of the resdents. Enough staff on duty to offer assistance in eating in an unhurried manner. The upstairs dining room does offer residents a congenial setting to dine in and requires decorating and a new floor covering. All staff to receive training in the protection of vulnerable adults. The upstairs dining room requires decorating and new flooring laid. Some chairs in the downstairs lounge need replacing. Additional staff to be on duty at peak periods of activity during the day. All staff to receive training appropraite to the work they Timescale for action 31/08/05 2. 3. 4. 2 12 15 31/08/05 31/08/05 31/08/05 5. 6. 18 19 18 23 31/08/05 31/08/05 7. 8. 27 30 18 18 31/08/05 31/08/05 Page 23 WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 perform. 9. 10. 31 38 8 13 The registered provider is to appoint an individual to manage the care home. All staff to complete trianing in health and safety. 01/07/05 31/08/05 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. Refer to Standard 27 Good Practice Recommendations To ensure that 50 of care staff are qualified to NVQ level 2 in care by 2005. WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Turton Suite, Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 WESTLEIGH LODGE F56 F06 S5703 Westleigh Lodge V217240 110505 Stage 4.doc Version 1.30 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. 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