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Inspection on 20/05/10 for Woburn Sands Lodge

Also see our care home review for Woburn Sands Lodge for more information

This is the latest available inspection report for this service, carried out on 20th May 2010.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents plans included a range of care plans to address needs in relation to their mental, physical health,personal care and social care needs. Care plans were person centred, detailed and specific as to how staff support residents to meet those needs whilst promoting their involvement and independence. They showed evidence of resident involvement in their development and were kept up to date and reviewed monthly. Care plans included records of one to one sessions with individuals with residents confirming that staff are always available to talk and offer support when required. The care plans included a risk assessment with a detailed risk management plan in place to address each identified risk. These were dated and signed by the resident and staff. They showed evidence of being reviewed three monthly or sooner where this was required. Alongside this the care plans included a moving and handling risk assessment and waterlow assessment. The home has a missing person policy in place to support staff in managing such situations. Care plans outlined the support required in meeting personal and health care needs and the support required in attending health appointment.The care plans viewed included appointment letters with relevant health professionals and evidence of regular care programme approach review meetings. At the time of the inspection the home had three residents who were self medicating under supervision. For all of the other residents staff administer their medication. Qualified nurses are responsible for the ordering, receipt, disposal , storage and administration of medication. The registered manager confirmed that the nurses have attended the National Pharmaceutical approved training with certificates of this training available for only some of the nurses working at the home. The medication administration records showed no gaps in administration of prescribed medication. The registered manager carries out monthly audits of medication with records maintained to support this.This monitoring is increased if issues are found. The supplying pharmacy do not carryout advisory visits and this should be addressed with them. The registered manager confirmed after the inspection that she had contacted the pharmacy to set this up. The home has a complaints procedure which is accessible to residents and staff. Residents fed back in surveys that they know how to make a complaint and residents spoken with during the inspection confirmed this. Staff spoken with confirmed that they know what to do if a resident made a complaint to them. Records of complaints are maintained and no complaints have been received since January 2009. The Commission have received no complaints in respect of this service. The home has a safeguarding and whistle blowing policy in place with a copy of the whistle blowing policy included in staff personnel files and signed by them. The home has a copy of the Local Authority safeguarding procedure with a flow chart on the notice board in the office to reinforce to staff action to be taken. Staff spoken with were clear of their responsibility to report bad practice. The staff on duty confirmed that they had completed the on line safeguarding training.One of the staff had also attended formal safeguarding training and the new staff member was booked to go on this course. The bank nurse on duty confirmed she had this training through her full time employer but no training record was on file to support this. Allegations of potential safeguarding incidents are handled appropriately and the home has had three safeguarding referrals and investigations during the period 2009. The communal areas of the home viewed were clean, homely and comfortable with a new carpet recently fitted throughout. Residents are supported and encouraged to take responsibility for the up keep of their bedrooms and personal space. Staff recruitment files viewed evidences that recruitment practices are robust which safeguards service users. The home is adequately staffed with four staff on daytime shifts and two waking night staff. The home has two cooks and a cleaner, with the cleaner post vacant at the time of the inspection. The registered manager works a mix of shifts and administration shifts. Staff feel that staffing levels are sufficient and residents confirmed that there is always staff available to meet their needs. Staff have access to formal mandatory, specialist training and on line training. The registered manager is actively involved with the Local Council in obtaining bids for specific training. The registered manager is qualified and experienced. Staff and residents fed back that the home is well managed and that the manager is approachable and accessible. Staff confirmed they feel supported despite not been regularly supervised and they can approach the manager for support and advice at any time. The registered manager carries out residents, relatives and professionals surveys to improve the service provided, however the results are not collated into a report to demonstrate that any issues raised are properly addressed. Staff are proactive in supporting service users with college and work placements and service users certificates of achievements are displayed in the nursing office to evidence those achievements.

What the care home could do better:

Service user health appointments are recorded in the diary, however a separate individual records of appointments with health professionals should be put in place to make access to this information more accessible. The correct code should be used on medication administration records to accurately reflect that a resident is on leave and had taken their medication on leave as opposed to being absent from the home. The home has a high number of medication records which were hand written and not printed by the supplying pharmacy. The registered manager confirmed after the inspection that this had been addressed with the supplying pharmacy. Residents are prescribed "as required medication", with some residents prescribed more than one for similar behaviours. Guidelines must be put in place as to why and when the "as required medication" is to be administered and if both "as required" medications can be administered at the same time to safeguard residents. During discussion it was confirmed that staff secondary dispense medication for leave, including planned leave. This is not considered safe or best practice and must be addressed with the supplying pharmacy for medications to be supplied by them for planned leave to safeguard residents. For unplanned leave a written procedure must be put in place for any medication transfers to be made to safeguard residents. A summary of complaints and safeguarding referrals should be maintained to include the date of the complaint, nature of the complaint , action taken and outcome. This will allow for monitoring of complaints and safeguarding. The staff supervision matrix indicates gaps in supervisions. The registered manager had identified that supervision was not taking place regularly.The manager has completed a supervision and management course and has introduced informal feedback sessions to be recorded as supervision. Some records were viewed to evidence this but the benefits and frequency must be reviewed and monitored to ensure that staff are supervised on a more regular basis. Induction, training and supervision records should be reorganised and made more accessible to fully demonstrate that staff are suitably inducted, trained and supervised to safeguard service users. During the inspection a new staff member on a POVA first went out with a service user unsupervised. This was because they had received their copy of their criminal records bureau check, which at that time was not on file. This was fed back to the registered manager to address. The registered manager confirmed after the inspection that the staff member had told staff on duty that they had received their copy of their criminal records bureau check as was the case, so the staff nurse on duty assumed that individual could now work unsupervised. The registered manager confirmed this has been addressed with staff concerned and she has reinforced in the communication book the rules around working on a POVA first. This needs to be maintained and effectively monitored tosafeguard residents. The manager confirmed that regulation 26 visits take place 4 to 6 weekly. Handwritten notes for a visit which took place on the 9/11/09 was made available. Following the inspection copies of regulation 26 visit reports were sent to the Commission for Dec 2009, Jan and February 2010. These were not fully completed to indicate the time and length of time in service. The registered provider must ensure that systems are in place to ensure that the home is being effectively monitored to safeguard residents, with reports maintained at the home to evidence this. An annual health and safety audit is carried out by a consultancy service annually. There are no others forms of quality monitoring taking place and the Provider needs to consider how this will be addressed and improved on. The registered manager confirmed after the inspection that audits take place on personal finance, management files, staff files, complaints, compliments, housekeeping, laundry, maintenance, kitchen, careplans and medication.

Random inspection report Care homes for adults (18-65 years) Name: Address: Woburn Sands Lodge 60 Station Road Woburn Sands Milton Keynes Buckinghamshire MK17 8RZ two star good service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Maureen Richards Date: 2 0 0 5 2 0 1 0 Information about the care home Name of care home: Address: Woburn Sands Lodge 60 Station Road Woburn Sands Milton Keynes Buckinghamshire MK17 8RZ 01908587677 01908587867 woburnsands@goldcareltd.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Elsie Bassey Ibok Type of registration: Number of places registered: Conditions of registration: Category(ies) : Gold Care Group Ltd care home 10 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Conditions of registration: 0 The maximum number of service users to be accommodated is 10. The registered person may provide the following category/ies of service only: Care home with nursing only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia (MD). Date of last inspection Brief description of the care home Woburn Sands Lodge is managed by Gold Care Ltd and was registered in July 2007 to provide residential and nursing care to adults who have a primary mental health need of a chronic and enduring nature. The home is registered to provide accommodation Care Homes for Adults (18-65 years) Page 2 of 11 Brief description of the care home and support for up to ten people The home is situated in the town of Woburn Sands on the outskirts of Milton Keynes. There are shops within easy walking distance and there are public transport links bus and train service to Milton Keynes and Bedford. The house has been extensively refurbished to meet individual needs. There is a kitchen, loungedining room and a separate smoking room. All of the bedrooms are single; some have an en suite toilet and shower. The home has a rear garden with a seating area to the side of the property. Please contact the provider to establish the current range of fees and how the fees are applied. Care Homes for Adults (18-65 years) Page 3 of 11 What we found: This unannounced random inspection took place as the home has not had a visit from the Commission since the 28th November 2007, when they received a good rating. The inspection lasted for five hours and was facilitated by the registered manager. It consisted of looking at records in relation to key outcome areas which included care planning, risk assessments, personal and health care needs of residents, including the safe administration of medication, complaints and safeguarding, staffing and management. The inspection also included discussions with residents and one to one discussions with two staff members. Resident surveys were sent to the home prior to the inspection and the feedback received from those indicates that residents who responded are happy with the care and support they receive. What the care home does well: Residents plans included a range of care plans to address needs in relation to their mental, physical health,personal care and social care needs. Care plans were person centred, detailed and specific as to how staff support residents to meet those needs whilst promoting their involvement and independence. They showed evidence of resident involvement in their development and were kept up to date and reviewed monthly. Care plans included records of one to one sessions with individuals with residents confirming that staff are always available to talk and offer support when required. The care plans included a risk assessment with a detailed risk management plan in place to address each identified risk. These were dated and signed by the resident and staff. They showed evidence of being reviewed three monthly or sooner where this was required. Alongside this the care plans included a moving and handling risk assessment and waterlow assessment. The home has a missing person policy in place to support staff in managing such situations. Care plans outlined the support required in meeting personal and health care needs and the support required in attending health appointment.The care plans viewed included appointment letters with relevant health professionals and evidence of regular care programme approach review meetings. At the time of the inspection the home had three residents who were self medicating under supervision. For all of the other residents staff administer their medication. Qualified nurses are responsible for the ordering, receipt, disposal , storage and administration of medication. The registered manager confirmed that the nurses have attended the National Pharmaceutical approved training with certificates of this training available for only some of the nurses working at the home. The medication administration records showed no gaps in administration of prescribed medication. The registered manager carries out monthly audits of medication with records maintained to support this.This monitoring is increased if issues are found. The supplying pharmacy do not carry Care Homes for Adults (18-65 years) Page 4 of 11 out advisory visits and this should be addressed with them. The registered manager confirmed after the inspection that she had contacted the pharmacy to set this up. The home has a complaints procedure which is accessible to residents and staff. Residents fed back in surveys that they know how to make a complaint and residents spoken with during the inspection confirmed this. Staff spoken with confirmed that they know what to do if a resident made a complaint to them. Records of complaints are maintained and no complaints have been received since January 2009. The Commission have received no complaints in respect of this service. The home has a safeguarding and whistle blowing policy in place with a copy of the whistle blowing policy included in staff personnel files and signed by them. The home has a copy of the Local Authority safeguarding procedure with a flow chart on the notice board in the office to reinforce to staff action to be taken. Staff spoken with were clear of their responsibility to report bad practice. The staff on duty confirmed that they had completed the on line safeguarding training.One of the staff had also attended formal safeguarding training and the new staff member was booked to go on this course. The bank nurse on duty confirmed she had this training through her full time employer but no training record was on file to support this. Allegations of potential safeguarding incidents are handled appropriately and the home has had three safeguarding referrals and investigations during the period 2009. The communal areas of the home viewed were clean, homely and comfortable with a new carpet recently fitted throughout. Residents are supported and encouraged to take responsibility for the up keep of their bedrooms and personal space. Staff recruitment files viewed evidences that recruitment practices are robust which safeguards service users. The home is adequately staffed with four staff on daytime shifts and two waking night staff. The home has two cooks and a cleaner, with the cleaner post vacant at the time of the inspection. The registered manager works a mix of shifts and administration shifts. Staff feel that staffing levels are sufficient and residents confirmed that there is always staff available to meet their needs. Staff have access to formal mandatory, specialist training and on line training. The registered manager is actively involved with the Local Council in obtaining bids for specific training. The registered manager is qualified and experienced. Staff and residents fed back that the home is well managed and that the manager is approachable and accessible. Staff confirmed they feel supported despite not been regularly supervised and they can approach the manager for support and advice at any time. The registered manager carries out residents, relatives and professionals surveys to improve the service provided, however the results are not collated into a report to demonstrate that any issues raised are properly addressed. Staff are proactive in supporting service users with college and work placements and service users certificates of achievements are displayed in the nursing office to evidence those achievements. Care Homes for Adults (18-65 years) Page 5 of 11 What they could do better: Service user health appointments are recorded in the diary, however a separate individual records of appointments with health professionals should be put in place to make access to this information more accessible. The correct code should be used on medication administration records to accurately reflect that a resident is on leave and had taken their medication on leave as opposed to being absent from the home. The home has a high number of medication records which were hand written and not printed by the supplying pharmacy. The registered manager confirmed after the inspection that this had been addressed with the supplying pharmacy. Residents are prescribed as required medication, with some residents prescribed more than one for similar behaviours. Guidelines must be put in place as to why and when the as required medication is to be administered and if both as required medications can be administered at the same time to safeguard residents. During discussion it was confirmed that staff secondary dispense medication for leave, including planned leave. This is not considered safe or best practice and must be addressed with the supplying pharmacy for medications to be supplied by them for planned leave to safeguard residents. For unplanned leave a written procedure must be put in place for any medication transfers to be made to safeguard residents. A summary of complaints and safeguarding referrals should be maintained to include the date of the complaint, nature of the complaint , action taken and outcome. This will allow for monitoring of complaints and safeguarding. The staff supervision matrix indicates gaps in supervisions. The registered manager had identified that supervision was not taking place regularly.The manager has completed a supervision and management course and has introduced informal feedback sessions to be recorded as supervision. Some records were viewed to evidence this but the benefits and frequency must be reviewed and monitored to ensure that staff are supervised on a more regular basis. Induction, training and supervision records should be reorganised and made more accessible to fully demonstrate that staff are suitably inducted, trained and supervised to safeguard service users. During the inspection a new staff member on a POVA first went out with a service user unsupervised. This was because they had received their copy of their criminal records bureau check, which at that time was not on file. This was fed back to the registered manager to address. The registered manager confirmed after the inspection that the staff member had told staff on duty that they had received their copy of their criminal records bureau check as was the case, so the staff nurse on duty assumed that individual could now work unsupervised. The registered manager confirmed this has been addressed with staff concerned and she has reinforced in the communication book the rules around working on a POVA first. This needs to be maintained and effectively monitored to Care Homes for Adults (18-65 years) Page 6 of 11 safeguard residents. The manager confirmed that regulation 26 visits take place 4 to 6 weekly. Handwritten notes for a visit which took place on the 9/11/09 was made available. Following the inspection copies of regulation 26 visit reports were sent to the Commission for Dec 2009, Jan and February 2010. These were not fully completed to indicate the time and length of time in service. The registered provider must ensure that systems are in place to ensure that the home is being effectively monitored to safeguard residents, with reports maintained at the home to evidence this. An annual health and safety audit is carried out by a consultancy service annually. There are no others forms of quality monitoring taking place and the Provider needs to consider how this will be addressed and improved on. The registered manager confirmed after the inspection that audits take place on personal finance, management files, staff files, complaints, compliments, housekeeping, laundry, maintenance, kitchen, careplans and medication. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 7 of 11 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 8 of 11 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 Medications required for planned leave must be obtained from the supplying pharmacy For unplanned leave a written procedure must be put in place for any medication transfers to be made by staff. To safeguard residents 18/06/2010 2 20 13 Guidelines must be put in 18/06/2010 place as to why and when as required medication is to be administered and if more than one as required medications can be administered at the same time. To safeguard residents. 3 39 26 The Provider must ensure 18/06/2010 that effective quality monitoring systems are put in place which include Regulation 26 visits with reports available at the home to evidence this. Care Homes for Adults (18-65 years) Page 9 of 11 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To ensure that the home is being effectively managed to safeguard residents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 10 of 11 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Adults (18-65 years) Page 11 of 11 - 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. 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