Inspection on 25/10/06 for Westleigh Lodge

This inspection was carried out on 25th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Westleigh Lodge 17/11/08

Westleigh Lodge 26/06/08

Westleigh Lodge 01/11/07

Westleigh Lodge 15/05/06

Westleigh Lodge 05/12/05

Westleigh Lodge 11/05/05

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 2nd Inspector Kath Smethurst Unannounced Inspection 25th October 2006 08:00 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 Westleigh Lodge DS0000005703.V309527.R01.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. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westleigh Lodge Address Nel Pan Lane Leigh Lancashire WN7 5JT 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) 01942 262521 01942 674783 www.schealthcare.co.uk Southern Cross Healthcare Services Limited Miss Michaela Marie Keeley Care Home 48 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (48) of places Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 48 service users, to include: Up to 48 service users in the category of DE(E) (Dementia over 65 years of age); Up to 3 service user in the category of DE (Dementia under 65 years of age) may be accommodated within the overall number of registered places The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 15th May 2006 2. Date of last inspection Brief Description of the Service: Westleigh Lodge is a purpose built three-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 a dementia illness. 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 and gardens at the rear. Accommodation 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 houses the homes kitchen, laundry and staff room. All residents have a single room with en suite facilities. The current rate of fees at Westleigh Lodge is £325.55 per week. Additional charges are made for hairdressing and chiropody. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection to Westleigh Lodge took place on the 25 October 2006 and included a site visit. Two inspectors carried out the inspection, from 08.00am until 4.45pm. The pharmacy inspector also visited the home to check the medication. The inspectors looked at records the home holds on residents (care plans) and other records the home needs to keep to ensure that the home is being run properly. The inspectors did a full tour of the building to check the environment, including the outside area. To find out more about the home one inspector spoke at length to a number of staff and visitors and where possible residents. Comment cards, asking people what they thought about the home and the care provided were sent to relatives and other visiting professionals, such as doctors and the community mental health care team prior to the inspection. As the home is caring for people with severe dementia it was not possible to get the written views of the residents. One relative said this about the home, “we are very happy with the care provided at Westleigh Lodge”. Another relative said, “The staff always seemed to be stretched at weekends, but they are always cheerful and helpful with care and consideration to all residents and visitors. I am very satisfied with the care my wife receives the staff are wonderful”. Two comment cards returned from doctors indicated that they were satisfied with the care their patients receive and they had not had any complaints about the services provided. In the main, responses made by health care professionals were positive apart from one comment stating, “ communication of the English language can often be difficult with overseas nurses. However, on the occasions this has occurred, staff supported each other effectively”. No complaints have been made to the management of the home since the last inspection and no complaints or concerns have been forwarded to the CSCI. What the service does well: Visitors can visit at any time and are made to feel welcome by staff when visiting relatives and friends. Visitors are offered refreshments and can stay and have a meal with their relatives. Several members of staff have worked at the home for a numbers of years and this helps provide consistent care for the residents living at the home. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Information regarding residents must be safely stored to ensure confidentiality is maintained at all times. (On arrival at the home it was noted that records were left unattended in the lounges). All staff must be suitably trained in appropriate moving and handling techniques, one inspector observed two members of staff using an inappropriate method (under arm lifting) when transferring a resident from a wheelchair to a chair. The manager also witnessed this method of handling and instructed staff in the correct procedure. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 7 In order to protect resident dignity,it would be more appropriate if continence products were removed from bathrooms and stored out of sight. The activities coordinator would benefit from an initial sum of money to allow her to purchase equipment required to plan and develop the activities, which would ensure the social needs of the resident’s can be addressed. There appeared to be insufficient space to accommodate residents in the dining areas. Dining rooms were very cramped with heated trolleys, cutlery and crockery trolleys, drinks trolley, wheelchairs, walking aids and staff. The atmospheres appeared chaotic and noisy. Some poor hygiene practices were noted in that two members of staff were serving sandwiches with their hands without using gloves or tongs. The corridor carpets on both floors need to be replaced as a priority; these were heavily stained and showing signs of wear and tear. There was a strong smell of urine in the corridors and in one resident’s room. This is unacceptable and must be eradicated. It was noted that whilst some new towels had been purchased, others were old and threadbare and need to be replaced. All waste bins must be replaced as a number do not have foot pedals, resulting in staff having to use their hands to open bins which could lead to cross infection. Residents would benefit from more orientation aids and pictorial signage to assist their movement around the home. The manager would benefit from her own office, this is currently shared with the administrator which makes it difficult for the manager so speak confidentially to people and for her to carry out her management duties. 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 DS0000005703.V309527.R01.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 Westleigh Lodge DS0000005703.V309527.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 were assessed standard 6 does not apply at Westleigh Lodge. Quality in this outcome area this outcome area is good. This judgement was made using available evidence including a visit to the service. The service user guide has been reviewed and now presents in a more acceptable manner to assist residents and their relatives make an informed choice about moving into the home. The pre admission assessment ensures that the home can offer the right level of care for residents. EVIDENCE: The service user guide has been reviewed to include photographs of what goes on within the home and shows what some of the bathrooms and bedrooms, lounges and the dining areas are like and pictures of some of the staff that work in the home are included. This may assist prospective residents with a dementia related illness to make a choice about moving into the home. The corporate information relating to Southern Cross Healthcare is still included within the guide. This information informs people about the structure of the Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 10 company and their philosophy of care, the complaints procedure and the aims and objectives of the home. Four care plans were inspected and in all files there was evidence that pre admission assessment had been carried out prior to admission. The home manager carries out assessments at the most convenient place for the prospective resident. Assessments cover the dependency levels of the resident including; waterlow/pressure areas, risk assessments, continence, personal care plans. The mental health needs of the residents are assessed including; health needs, sleep patterns, mobility, food and drink, and residents personality. The assessment ensures that the home and staff can meet the needs of the residents who have a dementia related illness and forms the base line for the care plan. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is adequate. This judgement was made using available evidence including a visit to the service. The records show that the health, personal care needs of the residents had been identified, were monitored and reviewed. EVIDENCE: Four care plans were looked at to see if full consideration had been made for each resident’s, health and personal care needs. On arrival at the home, the inspectors found information (moving charts, progress notes etc) about residents left unattended in the lounges. The inspectors removed these documents to the office. Staff spoken with indicated it was normal practice to leave these documents in the lounges. This was discussed with the manager who confirmed this practice would cease and records would be suitably stored. Each record contained sufficient information to enable staff to care for the residents. Care plans examined had been updated monthly as required. There was evidence to show that other professional health care workers had been contacted as and when required. Some effort had been made to include a Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 12 social profile of the residents past life and experiences; there is still some room for improvement in this area. Risk assessments were seen in the care plans inspected, relating to moving and handling, the use the use of bedrails, prevention of falls, nutritional needs and pressure care. While staff were seen to be kind and friendly towards residents it was noted that some residents spent most of the day walking around the home alone. The environment is safe and secure for residents to move freely around the home, however staff need to ensure that they spend time with these residents and provide some stimulation and purpose to their day. It was seen in some bathrooms that clean, continence products were on display in bathrooms, these should be stored away in either resident’s own rooms or in a cupboard in order to maintain residents dignity. The manager carried out a monthly check of medication handling and was aware of some weakness in the medication record keeping. She said that she also watched nurses during the medication round to make sure it was being carried out well. She explained that any concerns were discussed with staff so they knew where improvement was needed. Records of the receipt of medication into the home and of the safe disposal of unwanted medicines were maintained. These records are needed to track the safe handling of medication. Medicines are securely stored within the mediation rooms. Extra security was afforded to controlled drugs and (as required by law) their handling was recorded within a controlled drugs register. There were weakness in the record keeping and the administration of medicines to be addressed. Nurses administering medication had not followed the homes procedures for updating the medication administration records. They were poorly maintained and particularly unclear on the ground floor. The code ‘o/s’ (meaning out-of-stock) was frequently used on the ground floor. The nurse-in-charge said that the medicines marked o/s were either not needed or always refused. Regular refusal should be discussed with the prescriber and if the nurses are advised to continue to offer the refused medicines then, they must have some stock. There were no entries for the administration or refusal of some medicines. In one case the nurse was unsure whether two prescribed food supplements listed on the medication administered records were discontinued or not. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 13 Upstairs, nurses has signed for the administration of one tablet for a week when there were no tablets in stock and in fact, nurses said, the medicine was discontinued. Poor record keeping can lead to mistakes when giving residents their medicines. Nurses should adhere to the homes policies to make sure records are clearly maintained. At the previous inspection it was observed that the method of administration of medicines was inappropriate at times. At this inspection, medicines were no longer given whilst residents were eating but improvements still need to be made. Downstairs good support was given to residents who needed help to take their tablets and beakers of water were offered. But, on the first floor the nurse was seen to place several tablets (up to 5 or 6) onto a dessertspoon and give them all at once. Water was not offered in beakers but in the small medicines pots. On both floors the same spoons, water beakers and medicines pots were used to give medicines to several residents. This is unhygienic and must stop. One nurse explained that everything was wiped on a paper towel but this will not clean items, this is not acceptable practice. It is good practice to encourage residents to swallow tablets with water and it should be offered in clean beakers. It is difficult to swallow several tablets at once and this should be discouraged as it can lead to choking, or to tablets becoming stuck in the throat. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 14 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 and 15 Quality this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The frequency and variety of the activities for residents has improved offering more interest and variety to their lives. The meals in this home are satisfactory offering choice and catering for special dietary needs. EVIDENCE: Since the last inspection a new activity co-ordinator has been employed. Improvements to the range and frequency of activities were noted. However, the activities advertised did not correspond with what actually took place on the day of the visit. The activities advertised as taking place included the following: beauty hour (10.30 am), a trip to Pennington Flash (11.30 am), a pint in the pub (1.30 pm), leaf pictures (2.30 pm), arts and crafts (3.00 pm), movement to music (3.30 pm), guess the body parts (5.30 pm), hydrotherapy (6.30 pm), and happy hour (7.00 pm). This was not accurate. Discussion with the manager indicated this was a guide for staff rather than what would actually be offered. This is misleading and details of the programme should accurately reflect what is actually on offer. The new activity co-ordinator was spoken with. It was evident she was very enthusiastic about her role and she had tried to improve the range of activities provided with limited funds. She advised that the company provided £20.00 per week but any additional money Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 15 was raised through fund raising events at the home. The activity co-ordinator told the inspector she would like to purchase more games and craft materials but as funds were limited she was unable to do so. This was discussed with the manager and with the visiting operations manager who indicated it was not an issue and funds would be made available. Discussion with the activity co-ordinator indicated that it was difficult to motivate some staff to undertake activities with residents. This needs to be addressed, as the activity co-ordinator cannot ensure social needs are met without the input of more staff. On the day of the visit two residents were seen taking part in a “house work” activity (dusting and sweeping), both appeared to enjoy this. Four residents were seen taking part in card making, again they seemed to enjoy this. Future activities planned included a Halloween and Bonfire party, a trip to Blackpool illuminations (8 residents) and a Christmas meal at Smithills Coaching House (5 residents). In preparation for the trip to Smithills Coaching House the activity co-ordinator had been taking one resident out each week to purchase a new outfit. She found this very rewarding, as residents had responded positively to this. An example being, when she took one of the male residents to buy a new suit. The resident was very pleased with the outfit and when he tried it on said he “looked like a man”. Another inspector was told the planned trip to Blackpool illuminations had been cancelled as some staff had pulled out of the trip, resulting in there not being enough staff to accompany residents. Written records of activities residents take part in are maintained. The records of four residents were examined. It was noted that these activities had not been routinely completed. For example in one record the only activities were happy hour (02/10/06) and beauty care (04/10/06, while in another record, garden (02/10/06) and one-to-one discussion (09/10/06). This was discussed with the co-ordinator who said the records were not up to date as they took quite some time to complete and took a significant part of her shift to do so. The co-ordinator felt that a more simple way of recording how residents spent their time could be introduced allowing her more time to spend undertaking activities with residents. Discussion with the co-ordinator indicated the home did not have its own transport (ring and ride transport is used for trips) but she understood another home in the Southern Cross group did have a mini-bus. The manager should look into this to see if arrangements can be made to share the use of the bus to allow residents to go out of the home more frequently. The home has an open door visiting policy. There are no restrictions on the time people visit and this was evident, with visitors observed during various times during the course of the inspection. Further evidence was highlighted in Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 16 the visitor’s book where entries showed residents friends and relatives visiting at different times during the day and evening. Two visitors were spoken with and both confirmed staff made the welcome whenever they visited. All residents living in the home have memory and communication difficulties so were unable to confirm whether they were able to exercise choice. Care plans contain some information regarding residents being supported to make choices. Some examples of how staff supported residents to make choices were observed during the inspection. For example, the activity co-ordinator asked one resident if she would like to eat lunch in the lounge. The member of staff advised that this resident also liked her to bathe her. The activity coordinator previously worked as a care assistant and always made sure she bathed this resident. Although this member of staffs role had changed she continued to make sure she was available to assist with bathing. Staff were seen informing residents of meal options and showing them what meals were available. On the day of the inspection a cook from another Southern Cross home was providing cover. Prior to the inspection, menus were forwarded to the CSCI. Some improvements were noted, but further development is needed. For example, the sweet option at lunchtimes consists mostly of sponge pudding and custard and milk puddings. The provision of finger foods should also be incorporated in meals to allow residents who cannot or do not want to use cutlery to eat their food with their fingers. Some residents may not be able to sit at a table for any length of time and prefer to move around the home whilst eating would be able to do so if finger food was readily available. At breakfast time a member of staff was observed with a bowl of porridge following a resident who was walking round trying to feed him. This is not an acceptable way to assist in feeding a resident as the porridge was dropping off the spoon, the resident had food on his face and the whole process was not very dignified. The resident would have benefited from being offered a variety of finger food. Menus examined did not indicate evidence of there being any home made cake or sweet options offered. A flexible time for breakfast is not provided. Breakfast is served at 09.00 am. On the day of the inspection drinks (tea/coffee/fruit cordials/ biscuits) were served on the ground floor at 11.45. It was noted that plates were not provided for resident to put biscuits on. The main meal of the day is served at teatime. A light lunch was served at 12.45 pm. Lunch comprised of beef and vegetable broth, cheese and leek pasta, assorted sandwiches and cherry cheesecake or fruit. The soup was homemade and smelled good. With the exception of one table, all had tablecloths. The space in each of the dining rooms was not sufficient to accommodate the residents. Dining rooms were very cramped (heated trolley, drinks trolley, wheelchairs and staff). The atmosphere was less than Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 17 congenial, chaotic and noisy. It was noted that nursing staff were now assisting care staff serving meals. Some poor hygiene practices were noted in that a nurse and a care assistant served sandwiches with their hands instead of using tongs. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 18 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 and 18 Quality in this outcome area is good. This judgment has been made using available information including a visit to the service. The home has a suitable complaints procedure in place, residents and their supporters can be assured that their complaints and concerns will be listened to and appropriate action taken. The home has an adult protection policy ensuring that resident are protected from abuse in any of its forms. EVIDENCE: The have been no complaints made to the manager of the home or to the CSCI since the last inspection. Up to date policies and procedures on protection and safeguard residents from abuse in any of its forms were in place. Staff at the home had completed up to date training in the Protection of Vulnerable Adults. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is adequate. This judgment has been made using available information including a visit to the service. There has been some improvement to the standard of the environment; however further refurbishment is required to ensure that residents live in a pleasant, clean home. EVIDENCE: Some improvements were noted in the environmental standards. The day room on the first floor has been refurbished (redecorated, new curtains). More seating has been provided in corridors, which allows those residents who walk about the home to rest. Some bedroom doors have been painted in bright colours and had door knockers/letter boxes fitted. Signage still needs to be improved (toilets/bathrooms). The garden area at the rear of the building has been fenced and made secure. Decking has been installed and garden furniture purchased. It was noted that the grassed area had not been Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 20 landscaped. Consideration should be given to landscaping this area (hard landscaping and raised flower beds) to improve the outside space further. Corridor carpets (on both floors) need to be replaced as a priority. These carpets were heavily stained and showing signs of wear and tear. Odour control in the corridors/communal areas was also very poor with a strong smell of stale urine. When asked about the poor odour control the manager said she could not smell it, however other staff were asked and they were aware of the odour. The odour in one resident’s room was even worse. The manager advised that the resident had begun to urinate on the carpet and despite regular cleaning the odour remained. The manager said she had requested new flooring. This needs to be addressed as a priority as it is totally unacceptable for the resident to sleep in the room with such poor odour. It was noted that the dining room doors were locked. The manager advised this was due to safety considerations when cleaning and that a resident was prone to urinating in the upstairs dining room. Staff need to be more aware of this residents whereabouts in the home and provide appropriate supervision in deterring the resident from urinating in inappropriate places. This is undignified for the resident and creates an odour problem, which is unacceptable for other residents living at the home. It was noted that in addition to the normal locking mechanism a bolt had been fitted to the top of the dining room door (this gave an institutional appearance). All communal rooms, for example dining rooms and lounges should be unlocked to allow residents free access to these rooms. Staff should be suitably deployed around the home as to appropriately supervise resident’s movement around the home. While some new towels have been purchased it was noted that a number were old and threadbare and needed to be replaced. Some waste bins (toilets/bathrooms) need to be replaced, it was noted a number did not have a foot pedal resulting in staff having to use their hands to open the bin which could lead to cross infection. Continence products were seen on open display in some bathrooms need to be suitably stored. Some of bedrooms were examined and apart from the one bedroom with an odour, were clean, tidy and suitably furnished. Evidence of personalisation in some rooms was noted. The laundry was inspected. Two commercial washers, two commercial dryer and a rotary iron were seen and were in working order. Each resident had a separated box were laundered clothes were placed. The laundry was clean and tidy. One full time and one part time laundry assistant are currently employed. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 21 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 and 30 Quality this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staffing levels and the skill mix of the staff was satisfactory and appropriate to the needs of the residents. The standard of recruitment and selection practices were good ensuring the safety and protection of the residents living at the home. EVIDENCE: On the day of the inspection there were adequate number of staff on duty. Staff rotas were available for inspection. Information provided to CSCI prior to the inspection indicates that less than 25 of care staff have completed NVQ level 2 in care, this is low and the manager must ensure that at least 50 of care staff are trained to NVQ level 2 to ensure that they are experienced and competent to carry out their jobs and that residents are in safe hands at all times. Other staff training is ongoing and within the last year information provided by the manager to the CSCI shows that staff have completed training in protection of vulnerable adults, understanding dementia, person centred approach to dementia, moving and handling (although some staff were observed using inappropriate techniques), fire training, basic food hygiene (it was noted that some staff were serving food with their hands), palliative care Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 22 and COSHH (control of substances hazardous to health) training. Further training is planned and is to include challenging behaviour, protection of vulnerable adults, first aid, health and safety, infection control and dementia care; no dates were submitted for this training. It would be beneficial if a full training matrix were available in the office. This would enable the manager to see immediately when staff required mandatory training and when refresher courses are required. Four staff files were looked at. All files contained a written application form, two written references, Criminal Records Bureau checks, other forms of identification were seen on files for example copy of passport, driving licence and birth certificates. Some staff training certificates were seen on file. It was noted that in one file the staff induction was incomplete. The manager must ensure that all new staff complete a full induction programme within six weeks of their appointment to their posts, including training on the principles of care, safe working practices, the organisation and worker role, and the experiences and particular needs of the residents living at the home to enable them to offer appropriate care. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 23 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): 31,33,35,36 and 38 Quality in this outcome area is poor. This judgement was made using available evidence including a visit to the service. The manager’s lack of managerial experience has resulted in some practices, which do not promote and safeguard the welfare of residents living in the home. While some quality assurance systems are in place, further improvement is needed to ensure the home is regularly monitored and to evidence that residents/relatives views are sought and acted upon. There is a suitably accounting system in place to ensure that resident’s financial interests are protected. A supervision system needs to be developed to ensure that staff are well supported. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager has a nursing qualification and is working to working towards the NVQ level 4 award. The manager has recently undertaking a course in caring for people with dementia. Since the last inspection there has been some improvements noted in that the nurses in charge on both floors are now taking a more hands on approach and were seen providing more care and assistance at meal times. Care staff are now approaching the nurses for advice instead of the manager all the time. The manager has delegated some tasks, but still needs to be more assertive in some areas, for example on the day of the inspection a cook from another home was covering the kitchen, the manager came in her uniform to that she could assist in the kitchen, this is not her role. The manager needs an office of her own as currently the office is shared with the administrator. The office is busy with the telephone ringing, visitors wanting to leave money for residents and the general day-to-day tasks. The manager needs to be able to undertake her duties and be able to meet and discuss with visitors and staff any issues in private to ensure confidentiality is maintained. A new administrator had been appointed to, this should take some of the pressure of the manager. The administrator was spoken with and the inspector suggested that it may be helpful if she spent time with another more experienced administrator at another home, as she was still unaware of some of the administration duties and how to access information on the companies web site. Quality assurance is an area that needs to be developed. Due to the lack of communication with residents, it may not be possible to hold residents meetings, however relatives may like to be invited to meetings and be more involved in what goes in within the home. The visiting operations manager indicated that Southern Cross have sent out satisfaction surveys to relatives, however there was no evidence of the results or of any action taken. There was no evidence to demonstrate that the required monthly visit from senior management had been carried out and a written report completed. As the home had several requirements from the last inspection it is essential that home be visited by a representative of the company in order to monitor progress. The home has a suitable accounting system in place. Resident finances are individually kept and suitably stored. Four residents money were checked against the balance sheet and no discrepancies noted. Receipts of any transactions are kept. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 25 Staff are supervised by the manager and nursing staff on a day-to-day basis. It was noted that communication between the nursing staff and care staff was minimal. There was no evidence of staff having received any formalised supervision or of any appraisals having taken place. The manager was asked a number of times for the supervision records but was unable to produce them. This needs to be addressed to ensure staff receives the support they need to do their jobs properly. The manager is advised that formal supervision should be held six times a year and cover care practice, philosophy of the home and development needs. Fire safety records showed that fire drills had taken place regularly. The last drill took place on the 5/10/06. A number of different risk assessments were seen in various files. The manager did not appear to know which was the most up to date. In one of the risk assessments the names of the residents logged did not correspond with the residents living at the home while other fire assessments did not indicate when they had been completed. The manager needs to remove out of date risk assessments and ensure the most up to date is signed, dated and contains the correct information in respect to residents. The pre-inspection questionnaire provided details of maintenance checks undertaken by external contractors. A number were checked on site and were found to be satisfactory. It was observed by one of the inspectors that two members of staff when transferring a resident from a wheelchair into a chair were seen to be using inappropriate moving and handling techniques (underarm lifting). The manager was speaking with the inspector at this time and when the inspector brought this to the attention of the manager, the manager prompted the staff telling them of the appropriate way of transferring residents. The manager confirmed that staff should know better as they have all had up date training in this area. All accidents, illness and injuries were seen to be suitably recorded and the CSCI informed as necessary. Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 26 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x 3 1 x 2 Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 27 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. 1. Standard OP9 Regulation 17(1)(a) Requirement The registered person must ensure there is a complete, clear and accurate list of all currently prescribed medication for all residents, and of the date and time of administration. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person must ensure that there is adequate dining space provided separately from the resident’s private accommodation. The registered person must, having regard to the size of the care home and the number and needs of the residents ensure that, all parts of the home are kept and clean and are reasonably decorated with specific regard given to the corridor carpets on both floors which are dirty and heavily stained. The registered person shall, DS0000005703.V309527.R01.S.doc Timescale for action 30/10/06 2. OP9 13(2) 30/10/06 3. OP15 23(g) 15/12/06 4. OP19 23 (2)(d) 15/12/06 5. OP27 18 (1) (c) 15/12/06 Page 28 Westleigh Lodge Version 5.2 (i) 6. OP33 24 having regard to size of the care home, the statement of purpose and the number and needs of the service users ensure the persons employed by the registered person to work at the home receive training appropriate to the work they are to perform including structured induction training. Effective quality assurance 15/12/06 systems must be developed and results published to all interested parties including CSCI. (This is outstanding from the last inspection on 15/05/06 with a timescale given for 07/07/06) Monthly visits to the home from a named person from Southern Cross Healthcare must carried out and a written report produced. (This is outstanding from the last inspection on 15/05/06 with a timescale given for 07/07/07). 15/12/06 7. OP33 26 8. OP38 13 The registered person shall make 15/12/06 suitable arrangements to provide a safe system for moving and handling residents. 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 OP7 Good Practice Recommendations The registered person shall ensure that all records for example care plans are suitably and securely stored. DS0000005703.V309527.R01.S.doc Version 5.2 Page 29 Westleigh Lodge 2. OP10 The registered person should ensure that continence products should not be on display in bathrooms, these should be suitably stored in resident’s own rooms or in a cupboard. The registered person should ensure the activity coordinator would benefit from an initial sum of money to allow her to purchase a range of equipment to provide a range of activities. The registered person should ensure that residents are offered more variety to the desserts served at mealtimes. The registered person should give consideration to landscaping the grassed area to improve the outside space further. The registered manager should continue to work to complete the Registered Managers award. 3. OP12 4. 5. 6. OP15 OP19 OP31 Westleigh Lodge DS0000005703.V309527.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office 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 DS0000005703.V309527.R01.S.doc Version 5.2 Page 31 - 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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