Inspection on 24/07/06 for A Woodlands House

This inspection was carried out on 24th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

A Woodlands House 15/11/05

A Woodlands House 18/05/05

A Woodlands House 07/10/04

A Woodlands House 26/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE A Woodlands House 4 St Winefride`s Road Littlehampton West Sussex BN17 5NL Lead Inspector Ms B Tye Key Unannounced Inspection 24th July 2006 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 A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service A Woodlands House Address 4 St Winefride`s Road Littlehampton West Sussex BN17 5NL 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) 01903 725458 Mrs Oonagh Patricia Cacioppo Mr Gerard Bradford Hawkes Mrs Oonagh Patricia Cacioppo Care Home 14 Category(ies) of Dementia (14), Dementia - over 65 years of age registration, with number (14), Old age, not falling within any other of places category (4) A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only persons in the DE(E) (Dementia over 65 years) to be admitted to the home. 15th November 2005 Date of last inspection Brief Description of the Service: A Woodlands House is a home for older persons who suffer from dementia. It is registered to accommodate up to fourteen residents. Mrs O P Cacioppo and Mr G B Hawkes privately own the home, and Mrs Cacioppo is the registered manager involved in the day-to-day running of the business. A Woodlands House is detached and located in a residential area of Littlehampton West Sussex close to local amenities and the sea. The property is arranged on three floors. Accommodation comprises of ten single rooms and three double rooms, one of which is on the ground floor. A passenger lift serves the first floor. Only residents who can mange the stairs unaided should be accommodated on the second floor. There is a medium sized secluded garden to the rear of the building, with private parking to the front. Facilities include two lounges, comfortable seating in the entrance hall and dining room. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspection all relevant information and correspondence relating to the home was examined including a pre-inspection questionnaire completed by the homes manager. During the course of the inspection the inspector spoke to some of the people living in the home, interviewed staff and spoke at length to the manager. A tour of the premises was undertaken. The inspector observed lunch being served and staff interaction with residents. Four care plans and three staff files were examined and the inspector saw other records including, staff training, maintenance, incident and accident reports and all those relating to health and safety. This is the first inspection of 2006/2007. This is called a key inspection and will determine the frequency of visits/inspections hereafter. What the service does well: What has improved since the last inspection? Since the last inspection, a comprehensive maintenance programme for the building has been on going. Some rooms have been decorated. A new patio has been laid in the rear garden and a new kitchen and floor is currently being fitted at the home. A wash hand basin has also been fitted in the external staff toilet following a recommendation at the last inspection. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 123&5 Prospective residents and their families are able to visit the home before moving in, to assess the environment and quality of care provided. The manager or her deputy carries out an assessment prior to admission. This ensures resident’s needs are met appropriately by the home. The quality of this outcome area is good. This judgement has been made from available evidence including a visit to the service. EVIDENCE: Pre-admission assessments were examined for four residents. These identified relevant areas of need including; diet, communication, health, social and cultural needs. Additional information and correspondence by community based professionals is also held on file. This information is then translated into care plans and reviewed on a regular basis. All records are kept in a locked cabinet only accessible by care staff to ensure confidentiality. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 9 Risk assessments were in place for each of the four residents and contained information relating to their specific needs and assessed areas of risk. This promotes independence for residents in all aspects of daily living. Two residents stated they or their families had the opportunity to visit the home prior to admission. They were given information about the home including a Service Users guide. This information enabled them (and their families) to make an informed decision about moving to the home and what to expect. All residents have received a copy of their Terms and Conditions for the home, which they or their families had signed following admission. This informs residents of their rights and what to expect of the home. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 Arrangements are in place to ensure that the health care needs of residents are identified and met. Medication procedures are in place and staff had received dispensing medication training. This promotes good practice when dealing with medication. The quality of this outcome area is good. This judgement has been made from available evidence including a visit to the service. EVIDENCE: Four residents care files were case tracked. Each care plan held information relating to residents assessed need and personal requirements, along side details of their health, well-being and social preferences. A brief daily entry of any changes in the resident’s health is recorded in a kardex file and also contains GP and district nurses’ input. The care plans of two residents recently admitted to the home were examined. They were comprehensive and gave clear details of their individual needs and preferences. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 11 Individual files contained risk assessments including moving and handling. Any significant event regarding the well -being of a resident is recorded and care plans are updated either monthly or as changes occurred. Specialist health needs are referred to community-based professionals via the GP’s. Correspondence held in individual files supported this. The home has an up to date policy, procedure and regular staff training relating to dispensing medication. Medication charts and storage of medicines within the home were examined. These are maintained efficiently. The residents seen during the visit were very tidy in appearance wearing appropriate clothing with their nails and hair well groomed. Residents stated that ‘staff were wonderful’ and ‘always on hand if needed’. Most residents were alert and cheerful. Staff were observed communicating with them in a caring and respectful manner. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Residents are supported to make choices where possible. Residents said their families were made to feel welcome when they visited. The mealtimes are well managed. The food is nicely presented and varied according to dietary requirements. The quality of this outcome area is good. This judgement has been made from available evidence including a visit to the service. EVIDENCE: Residents stated they were able to exercise choice regarding activities. One said she preferred to remain in the home and enjoyed participating in ‘lounge games’ organised by the staff. These include jigsaws, music, exercises and crafts. The home organises hand and feet massages for the residents. Local walks and monthly organised outings. The home has employed a part time activities co-ordinator, who arranges either one to one or group activities, on a daily basis. Residents are encouraged to maintain contact with their family wherever possible and visitors are welcomed to the home. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 13 Staff were observed chatting with some of the residents and the interactions between them was relaxed and friendly. The meals looked appetising and were generous in quantity. During lunch, some of the residents chose to sit in the garden to eat, as the weather was warm. Alternatives to the main meal were being provided as appropriate. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has provided residents and their families with information in respect of complaints. Staff have received POVA training to ensure they can respond appropriately, should an issue of suspected abuse arise. The quality of this outcome area is good. This judgement has been made from available evidence including a visit to the service. EVIDENCE: Information about complaints is provided as part of the Service Users Guide. This information is supported by policies and procedures at the home, and distributed to family members as well as residents. The Commission has received no complaints since the previous inspection. The home holds a complaints log and no entries had been made since the last inspection. Staff members are participating in training leading to a National Vocational Qualification Level 2 or 3. This would promote awareness of what constitutes bad practice. All staff have undertaken recent POVA training to ensure they respond appropriately to suspected abuse. A copy of the West Sussex County Council Multi Disciplinary Adult protection Policy is kept in the office for reference. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 15 The procedures for the recruitment of staff are robust and provide the necessary safeguards to offer protection to the residents living in the home. All care staff have undertaken a Criminal Records Bureau enhanced check to ensure they are suitable to work with vulnerable people. Residents said they felt ‘listened to and were able to discuss concerns with staff.’ A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 16 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 – 26 The communal areas of the home and residents bedrooms were clean and homely providing the residents with a pleasant living environment. Specialist equipment is provided to maximise the independence of residents. A requirement has been made to make the bathroom radiator safe. The quality of this outcome area is good. This judgement has been made from available evidence including a visit to the service. EVIDENCE: Following a tour of the premises and examination of maintenance records it is evident the home provides an overall homely, well-maintained and safe environment. The residents have access to a main communal lounge/dining room and a smaller lounge leading to the garden. The home is comfortably furnished, creating a homely environment. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 17 There is a passenger lift for residents with limited mobility to access all floors of the house. Some radiators throughout the home have been covered to reduce the risk of injury, however the bathroom radiator was switched on and uncovered posing a potential risk. A requirement has been made to make this safe. A call bell is provided in every room so staff are aware and can attend an emergency situation should it arise. Bedrooms were furnished with personal possessions and the option is given to bring furniture from home, giving each resident a sense of ownership in their private space. Access to one bath in the home is managed by providing a weekly bath rota. Residents spoken to stated ‘we can have a bath when we like’. Some bedrooms offer en-suite facilities. A cleaner is employed 5 days a week to ensure the premises are kept clean. All areas of the home were found to be very clean and tidy, providing the residents with a clean environment and minimizing the risk of infection. Policies and procedures are in place for infection control, and records showed all of the staff have attended training. During the visit it was noted a new kitchen was being fitted in the home. This has been organised in stages to avoid disruption to mealtimes whilst works are being undertaken. The kitchen area was well maintained and clean despite the disruption. Environmental risk assessments are completed prior to resident’s admission to ensure rooms are safe and well maintained. An entire new fire alarm system has been fitted to the home in recent months. During the tour of the premises it was noted there were some areas of disrepair in the home including two broken door handles and a leaking sink in a residents bedroom. The provider has recently employed contractors to ‘make good’ areas in the home needing attention. Since the beginning of the year an ongoing programme of redecoration and improvement has been underway. The inspector was able to view a comprehensive maintenance plan and contractors quote for pending work. All areas noted during the tour had been identified by the provider and were included in the quote for forthcoming work. As a consequence no requirements or recommendations were made. The completed works can be monitored at the next inspection. The visit took place on a very hot day and it was noted some doors had been kept open to create a through breeze and keep the rooms cool. It was recommended this practice be risk assessed in conjunction with the fire officer, to ensure the safety of residents was maintained. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 18 A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 19 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 - 30 Recruitment procedures and record keeping are adequate to ensure that residents are protected in the home. The staff numbers are sufficient to meet the assessed needs of residents. An induction and comprehensive training programme for staff is provided, to ensure residents specialised needs are met in full. The quality of this outcome area is good. This judgement has been made from available evidence including a visit to the service. EVIDENCE: It was concluded from examining the duty rotas, speaking to staff and residents and information accessed in individual files, that staffing levels are sufficient to meet assessed needs of residents. One resident said ‘staff are always there whenever they are needed’ The manager stated that extra staff are always available at peak times or if a resident required extra care. Rotas seen, supported this. Records showed that staff complete a induction prior to working with the residents, then go on to undertake a comprehensive training programme specific to the needs of residents. In addition, the required ratio for 50 of staff to complete NVQ Level 2/3 or equivalent by 2005 has been met. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 20 This ensures residents who have specialised needs such as depression, mental health issues and forms of dementia will have their needs appropriately met by staff within the home. Staff members spoken to, demonstrated commitment and a clear understanding of the resident’s needs. Several of the staff are qualified health care workers from abroad and have a range of relevant skills. The staffing records showed that the staff group are fairly consistent and some have worked at the home since it first opened in 1990. Records showed that staff meetings occur on a regular basis to ensure staff have a clear understanding of their role and responsibilities. The manager is on duty most days, in her absence her deputy takes charge of the day to day running of the home. Recruitment policies and procedures are in place, to ensure staff employed by the home have the necessary skills and experience to fulfil their roles. CRB checks, terms and conditions and references were seen on file for staff members. This ensures that residents are protected in the home. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 21 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 - 38 Staff do benefit from the leadership and management approach within the home. However, supervision is not undertaken on a regular basis. A requirement has been made in respect of this. The overall quality of this outcome area is good. This judgement has been made from available evidence including a visit to the service. EVIDENCE: An annual development plan and quality assurance system is in place, which includes contributions from residents and their families. Use of consultation with residents, staff and their families ensure those providing and receiving care have an input into how the home is run. Feedback from relatives included comments such as ‘ we are more than happy with the home’, ‘I am very appreciative of the good care provided’ and ‘any A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 22 suggestions we make are always received sympathetically by staff’, ‘overall we are more than satisfied’. There were no negative comments made about the service although one relative suggested it would be useful for staff to wear name badges and to have a photo board of staff on display in the home. Regular staff meetings mean staff are kept up to date with changes and able to give their views about how the home is run. Staff spoken to stated they received support from management and their peers. Records reflected supervision sessions for staff were not held on a regular basis. A requirement has been made in respect of this. No resident is responsible for their finances due to their mental frailty; this is undertaken by a family member or solicitor acting on their behalf. All additional expenditure by residents is invoiced to appropriate parties by the home. Resident’s possessions and valuables are logged and signed for on their admission. There were some gaps in the fire alarm checks due to a new system being installed in the home. Health and safety records including risk assessments, incident logs, accident book, equipment checks and on going maintenance plans were found to be in good order and up to date. Overall it was concluded the residents are priority within the home, appropriate record keeping supports this. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 23 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 1 3 3 A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 24 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 2 Standard OP36 OP19 Regulation 18 (2) 13(4) Requirement To ensure staff are supervised no less than 6x annually. To ensure radiator in bathroom is made safe to avoid potential injury to residents. Timescale for action 24/09/06 24/08/06 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 OP25 Good Practice Recommendations To risk assess fire doors left open during warmer weather in conjunction with fire officer. A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Southampton Hub 4th Floor, Overline House Blechynden Terrace Southampton Hampshire SO15 1GW 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 A Woodlands House DS0000014852.V294887.R01.S.doc Version 5.1 Page 26 - 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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