Inspection on 13/12/05 for Chestnut Court

This inspection was carried out on 13th December 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chestnut Court 10/04/07

Chestnut Court 05/07/05

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Woolstrop House St James Quedgeley Glos GL2 4WD Lead Inspector Mrs Eleanor Fox Unannounced Inspection 13th 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 Woolstrop House DS0000064586.V266927.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. Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woolstrop House Address St James Quedgeley Glos GL2 4WD 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) 01452 720049 The Orders of St John Care Trust Miss Louise Samantha Turley Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Woolstrop House is a purpose built Care Home, situated within easy reach of a large retail area, approximately 5 miles from the centre of Gloucester. The Home provides nursing and personal care to 40 elderly people. The Home is made up of 5 independent units connected by link corridors. Each unit provides single accommodation for 8 residents plus a small kitchen, dining room and lounge area. All are attractively decorated and comfortably furnished, ensuring a friendly homely atmosphere. The Home also has a large main kitchen where most of the catering is undertaken and a day centre for the local elderly community. The attractive landscaped garden is easily accessible and enjoyed by the residents during the summer months. Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced inspection over a period of four hours. During the day she talked to seven of the residents, read their care records, visited their bedrooms and observed their interaction with members of staff. She also observed the service of the mid-day meal. The inspector spoke with three visitors and various members of staff, and looked at a selection of recruitment records and other documents, which were available in the home on that day. Comments and views of some of the people who met the inspector have been reflected in this report. Finally, the inspector talked to the Manager, who was on duty during the day and who was most cooperative in providing information as requested. What the service does well: What has improved since the last inspection? Improvements have been introduced in the recruitment processes employed at the Home ensuring that each applicant is subject to full screening processes prior to being appointed to work at the Home. Financial management procedures are now fully implemented to ensure that accurate records are maintained. Health and safety measures have also been introduced to ensure that water temperatures are maintained at safe levels. Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 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. Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 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 Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 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): 2 and 3 A thorough assessment process enables prospective residents to make an informed decision regarding their admission and gives them assurance that their needs will be met. Some further information must now be provided to residents at the Home. EVIDENCE: All residents admitted to Woolstrop House are provided with a copy of the Terms and Conditions for admission to the Home. Signed copies of this documentation are maintained in the records. There is a form prepared, identifying the breakdown of fees in the pricing structure charged to the resident. However, the Home does not yet share this information with the resident or the person responsible for settling the accounts. This process must now be introduced One person was about to be admitted to the home. All the documentation prepared for this prospective resident was observed. The Manager had undertaken a very thorough assessment in the hospital ward, maintaining clear Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 9 records of her findings. She had also been provided with a copy of the Social Services assessment for this person to assist the processes. Arrangements had been made for the delivery of a bed to suit the prospective resident’s particular care needs. Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 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 and 10 The care planning systems in place adequately provide the staff with the information they require to care for all the residents’ needs. Care is delivered in a manner that preserves the residents privacy and upholds their dignity. EVIDENCE: The Home develops a care plan for each resident based on a full assessment of care needs; seven examples were read in detail on this visit. In each case, specific care plans had been prepared to address all identified needs; these were clearly written and contained the information required for the carers to provide appropriate care. All were reviewed and updated in a timely fashion. Risk assessments were also completed and reviewed, as appropriate. In addition to the routine reviews of care needs, the Home has introduced a new system to completely review all areas of care for each resident. This is discussed during a meeting with the resident, care staff, and usually includes a close relative or advocate, on a 6 monthly basis. The first eight of these reviews have already been conducted; the Deputy Manager confirmed that Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 11 they have been of benefit to all concerned. It was observed that the resident or family member signs the reviewed care plans at this meeting. Members of staff were observed addressing the residents in a friendly but respectful manner. They knocked on residents’ doors prior to entering and attended to any personal care discreetly behind closed doors. Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 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): 14 and 15 The Home’s positive approach to residents being able to make choices and carrying out their personal preferences is reflected in the behaviour of the residents and the attitude of the staff. A good choice and variety of meals ensures residents receive a nutritious and balanced diet. EVIDENCE: Residents are assisted to make choices in their daily lives and to be as independent as possible. Advice on how to source advocacy support is also readily available to anyone requiring this service. Residents are free to personalise their rooms with pictures, small items of furniture and treasured possessions. Although living in a large care home, the residents are accommodated in small units of eight people, promoting a friendly homely atmosphere. Twelve of the residents were taken out for a Christmas lunch on this day; the remainder ate their meals in one of the five small dining rooms in the Home. They were given the opportunity to eat their food in a peaceful unhurried fashion. Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 13 There is a choice of two main dishes each day but other alternatives are also available. One person preferred to eat a vegetarian dish and another requested sliced corned beef with vegetables. Some people required their meals to be served in liquidised format. These were also served in a fashion to ensure that they still appeared appetising. Observation of the menus showed that the residents receive a varied choice of food. Cooked breakfasts are provided, if desired. The kitchen was clean and well organised. Woolstrop House DS0000064586.V266927.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): 18 The employees’ knowledge and understanding of the Home’s Adult Protection procedures helps to provide a safe environment for the residents. EVIDENCE: The Home has documented policies and procedures addressing all areas of abuse. Members of staff receive training on these topics and will be attending a seminar on the subject early in the New Year. The Department of Health’s ‘No Secrets’ advice is readily available in the nurses’ room and other relevant advisory documentation is also provided. Members of staff are informed formally that they may not benefit from a resident’s will or accept any gifts. Members of staff provide signed confirmation that they are aware of this policy. Woolstrop House DS0000064586.V266927.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 and 25 Some minor improvements to the environment would provide residents with a good standard of homely accommodation. EVIDENCE: A tour of the Home showed that the Home is maintained and decorated to a reasonable standard. The handyman is responsible for undertaking an ongoing programme of redecoration; he is painting the corridor areas at the current time. It was observed that many of the bedroom doors now required some minor attention, as does the bathroom in the unit known as Arlingham. The whole home had been decorated in a festive fashion in preparation for Christmas. It was reported that a replacement call bell system would be installed at the home in 2006. In addition, a replacement bath would be installed in Perry Way and a shower room provided for Arlingham. Since the last inspection, an adjustment has been undertaken to the hot water system to ensure that the hot water in resident areas flows at an acceptable Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 16 temperature. Recent records were provided to show that these levels continue to be maintained safely. In the meantime, mixer valves are being installed throughout the Home; this work should be completed by the end of 2005. Environmental risk assessments have been reviewed and updated to accurately reflect the situation in relation to the hot water systems. Woolstrop House DS0000064586.V266927.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 Residents receive care from a stable competent workforce; the recruitment practices that are followed help to ensure residents are fully protected. EVIDENCE: On this visit all the records relating to members of staff employed since July 2005 were observed. In all three examples, full recruitment procedures had been followed. The prospective employee had completed an application form and medical questionnaire and had attended a formal interview. Records are maintained of the processes. These provide evidence that any missing information about employment history and the reason for any gaps in employment are discussed. Two written references and enhanced Criminal Record Bureau screening is completed. Employees are fully inducted to their new roles. As identified at previous inspections, a significant amount of formal training is undertaken at this Home, including fire awareness, food hygiene, and manual handling, etcetera. Comprehensive records are maintained to ensure that all mandatory training is addressed in a timely manner. All members of staff work in a supernumerary capacity when they commence their employment. Each employee also attends a two-day corporate induction course. Woolstrop House DS0000064586.V266927.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): 31, 33 and 35 There is a thorough programme of self-review and consultations in place at the Home; some additional details are required to ensure that residents gain full benefit from these processes. There are also good management systems in place to ensure that the residents’ rights are safeguarded. EVIDENCE: The Manager has attended an interview at the Commission for Social Care Inspection and has now been registered in this position. She is progressing well with her studies to achieve the Registered Managers Award. The Home continues to have a good focus on quality improvement. Medication administration, care planning documentation, any complaints, accidents or adverse incidents, and satisfaction with the provision of food are all monitored Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 19 closely. The Home has also just been successfully assessed in an external quality audit. However, a quality improvement report has not been provided for the Home in the last twelve months, as is required. The administrator looks after the personal monies for most of the residents. These are kept in individual envelopes and are locked away securely. All transactions are fully documented and countersigned. Checks undertaken on this occasion showed that these are all recorded accurately. Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 20 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 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 2 x x x x x 3 x STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x x Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 21 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 OP2 Regulation 5a Requirement Where a nursing contribution is paid in respect of nursing provision at the home to a resident, the home must issue a statement to the resident or the person responsible for settling any accounts specifying: a) The date of payment and the amount of the nursing contribution; and b) Either i) the date (if any) on which the Registered Person is to pay the amount of the nursing contribution to the service user or deduct that amount from the fees; or if the nursing contribution is not to be so paid or deducted, whether and if so how it is taken into account for the purpose of calculating those fees. 31/03/06 Timescale for action 31/01/06 ii) 2. OP19 23(2d) 3. OP33 24(2) Decorative improvements to scratched bedroom doors and to the bathroom in Arlingham must be addressed. A quality improvement report DS0000064586.V266927.R01.S.doc 31/03/06 Page 22 Woolstrop House Version 5.0 must be provided for the home RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woolstrop House DS0000064586.V266927.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. 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