CARE HOMES FOR OLDER PEOPLE
Westleigh Lodge Nel Pan Lane Leigh Lancashire WN7 5JT Lead Inspector
Judith Stanley Unannounced Inspection 5th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 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.V258288.R01.S.doc Version 5.0 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 Southern Cross Healthcare Services Limited Care Home 48 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (48) of places Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 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 1 service user in the category of DE (Dementia under 65 years of age). The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 11th May 2005 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. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over a 4- hour period on one day. The first part of the day was spent observing and talking with staff and the acting manager as they carried out their regular morning duties. The remainder of the visit was spent looking at some records the home holds on residents (care plans) and speaking with 3 relatives and residents, as well as making a tour of the premises. Due to the high numbers of residents at the home with advanced dementia it was difficult to ask residents views about the care and services they received. Prior to the inspection comment cards were sent to the home to be given out to service users, relatives and other visiting professionals, for example GPs, care managers and social workers. One comment card has been returned from a care manager and two from relatives. What the service does well: What has improved since the last inspection?
Since the last inspection the acting manager has applied for the post permanently and is currently progressing through the CSCI procedures. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 Page 6 It was noted that the downstairs lounge has been recently decorated and some new furniture has been bought. What they could do better:
The decorating in the upstairs dining room is poor and the floor covering is not suitable and needs replacing. This was left as a requirement at the last inspection and the acting manager has discussed this with senior management but to date nothing has been done to make these improvements. An immediate requirement was issued for this to be actioned. The odour in the upstairs lounge must be eradicated and the carpet in both the lounge and corridor needs replacing due to it be heavily stained. All staff must be fully trained in caring for people with dementia. Staff need to be more aware of the different types of dementia and the best ways that they can care for residents and meet their different needs. This was left as a requirement at the last inspection and the acting manager has discussed this on numerous occasions with senior management. The acting manager and staff spoken with confirmed that no in depth training has been provided by the company. An immediate requirement was issued for training to be implemented. The home needs to be better equipped with signs and symbols to assist residents with orientation and recognition. All staff must be trained in the protection of vulnerable adults and all staff to have regular updates in health and safety matters. The acting manager and staff confirmed that some staff had received updates in health and safety issues; however no in depth training has been provided by the company to ensure the protection of vulnerable adults. This training matter was left as a requirement at the last inspection. The acting manager confirmed that this training issue had been discussed with senior management but is still outstanding. An immediate requirement was issued for training to be implemented. Certain areas of the home are in need of attention for example in bathrooms and toilets, no extractor fans appeared to be working, and in one toilet there was no lid on the cistern. It was also noted in some bedrooms that the borders were ripped and several light fittings had bulbs missing. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 Page 7 It was noted that trolleys with spare towels and bedding were being stored in the bathrooms. These need to be removed, if a resident was in the bath, staff would be going in to get fresh bedding as needed which is unacceptable. 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.V258288.R01.S.doc Version 5.0 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.V258288.R01.S.doc Version 5.0 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, standard 6 does not apply to this home. The homes service user guide does not provide sufficient information in a suitable format for residents and relatives to make an informed choice about coming to live at the home. The pre assessment information is basic and does not focus enough on the mental health/dementia care needs of the prospective residents to ensure the home can offer the right level of care needed. EVIDENCE: There was no evidence to show that improvements had been made to the service user guide to make it a more accessible document for residents with dementia. As previously discussed the format of the guide should contain pictorial information about the layout of the home, bedrooms, mealtimes, staff and what goes on in the home. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 Page 10 Based on a pre assessment visit prior to admission into the home, an individual care plan is drawn up; these are maintained on file. However, the acting manager discussed that the assessment format does not focus enough on the mental health/dementia care needs of the residents and that a full dementia assessment is not completed until the resident has moved in to the home. This should be discussed with senior management to ensure that the resident’s needs are fully assessed and documented and that the home is suitably equipped to fully meet the residents needs. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 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 and 9 In the main, the standard of care planning and review was satisfactory, providing staff with the information they needed to meet the resident’s basic care needs. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure resident’s medication needs are met. EVIDENCE: Three care plans were looked at. Each record set out in detail the aspects of health; personal and social care needs of the resident. Due to all residents having a diagnosis of dementia, the home relies heavily on input from the relatives in building up a working plan, however not all plans had been signed by relatives to indicate that they were in agreement with what was
Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 Page 12 documented. Care plans had been updated as and when any changes occurred but had been updated at least once a month as required. The content of the care plan is based on the initial assessment, but as previously stated (refer to standard 3) the acting manager feels that a more in depth assessment is required. Risk assessments have been written for each person, these covered, moving and handling, falls, nutrition and pressure areas. The morning medication round was observed. The nurse in charge had only been at the home for two weeks but confirmed that the first week was spent on induction training. Medicines were given in an appropriate manner and suitably recorded on the individual’s drug sheet (MAR sheet). Whilst it was noted that most MAR sheets had a picture attached of the resident some were missing. It was discussed with nurse that it would be beneficial to all staff, especially new staff if a picture was attached to all MAR sheet on admission to avoid any mistakes or errors. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: None of the key standards were inspected on this occasion. These will be inspected at the next inspection. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 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 and 18 Systems were in place with regard to the investigation of complaints ensuring that residents are protected. Arrangements for protecting residents from abuse are not satisfactory placing them at possible risk or harm. EVIDENCE: The home has a complaints procedure that is advertised within the home. Due to the high levels of dementia, residents would find it difficult to complain and rely on relatives/advocates to act on their behalf. Since the last inspection there has been no complaints made to the management of the home and no complaints have been forwarded to the CSCI. The home has the relevant policies and procedures relating to vulnerable adults. The acting manager and staff confirmed that no formal training had been given by the company with regard to the protection of vulnerable adults. Given the high level of dependency of the residents and the demand placed on staff it is imperative that all staff undertake appropriate training in this area and that it is updated at least every two years. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 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 The standard of décor and maintenance in parts of the home does not provide residents with a comfortable, homely place in which to live. EVIDENCE: From a tour of the premises, it was evident that the ground floor is decorated and maintained to a higher standard than the first floor. This is not acceptable and must be addressed to ensure that all residents are offered the same standard of accommodation. The dining room on first floor needs decorating and a new floor covering fitted. The upstairs lounge must be decorated to the same standard as the downstairs lounge. The odour in the upstairs lounge must be eradicated; the carpet should be replaced as it is now passed the point of deep cleaning. New chairs are also required in the upstairs lounge. Staff spoken with were despondent about the differences in décor and comments made included, “ this floor is second class” and “it’s not fair that residents on the ground floor are living in better conditions than up here”.
Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 Page 16 It was noted that some bathrooms and toilet require attention, for example the extractor fans did not appear to be working and a lid was missing off a toilet cistern. The outside garden area requires attention before the warmer weather, as the area is not safe for residents to go out unaccompanied. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 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 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): 29 and 30 The procedures for the recruitment of staff are rigorous robust and do provide the safeguards to offer protection to people living in the home. Staff had not received appropriate training therefore placing residents at potential risk. EVIDENCE: From inspection of staff files it was evident that all the necessary checks had been undertaken to ensure the protection of residents. Criminal Records Bureau Checks (CRB) are obtained prior to commencing work and suitable written references sought. Staff spoken with confirmed that they had not received in depth training in caring for people with dementia and did not fully recognise the different types of dementia. As the home is offering care to residents with a dementia illness it is imperative that all staff are suitably trained to offer the right care needed. Staff confirmed that they are working with a very vulnerable client group and staff spoken with felt it would be beneficial to undertake training in the protection of vulnerable adults. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 Page 18 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): EVIDENCE: None of the key standards were inspected on this occasion. These will be inspected at the next inspection. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 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 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 1 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 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. 1. Standard OP1 Regulation Sch 1 Reg 4(1)(c ) Requirement The format of the service user guide needs further review in order to meet the standard required. (This is outstanding from the last inspection31/08/05) The pre assessment format must ensure that the needs of the residents can be fully met with regard to their mental health and dementia needs. All staff must receive training in the protection of vulnerable adults. (This is outstanding from the last inspection – 31/08/06) The upstairs dining room requires decorating and new flooring laid. The upstairs lounge requires a new carpet to eradicate the odour. (This is outstanding from the last inspection -31/08/05. The garden areas are to be made safe for residents. Some bathrooms and toilets require attention to decor. All staff to receive training
DS0000005703.V258288.R01.S.doc Timescale for action 30/01/06 2. OP3 14 31/01/06 3. OP18 18 31/01/06 4 OP19 23 31/01/06 5 6 7 OP19 OP19 OP30 23 23 18 01/03/06 31/01/06 31/01/06 Westleigh Lodge Version 5.0 Page 21 8 OP38 13 appropriate to the work they perform. All staff to complete health and safety training (This is outstanding from the last inspection – 31/08/05) 31/01/06 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 OP27 Good Practice Recommendations To ensure that 50 of care staff are qualified to NVQ level 2 in care by 2005. Westleigh Lodge DS0000005703.V258288.R01.S.doc Version 5.0 Page 22 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
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