Inspection on 05/07/05 for Chestnut Court

This inspection was carried out on 5th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chestnut Court 10/04/07

Chestnut Court 13/12/05

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 Gloucestershire GL2 4WD Lead Inspector Eleanor Fox Unannounced 5 July 2005, 09:30 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 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 D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woolstrop House Address St James Quedgeley Gloucestershire GL2 4WD 01452 720049 01452 722583 manager.woolstrop@osjctglos.co.uk Orders of St John Care Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) To be arranged Care Home 40 Category(ies) of OP old age (40) registration, with number of places Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration. Date of last inspection 6/12/04 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 D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 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 5.5 hours. It consisted of a full tour of the property; inspection of a selection of written care records; recruitment files and other available documents; plus discussions with the Acting Manager, the Administrator and members of staff working in the Home. The inspector had the opportunity to talk to twelve of the residents and to three relatives who were in the Home during her visit. She also observed part of the service of the lunchtime meal and attended a planned activity during the afternoon. Management of the Home has recently become the responsibility of The Orders of St. John Care Trust; the Commission for Social Care Inspection has fully processed their application for registration. The Acting Manager has also submitted an application to become the registered manager of Woolstrop House. She will be interviewed for the appointment shortly. What the service does well: What has improved since the last inspection? There has been a significant improvement in the standard of medication administration records; these are now consistently completed correctly. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 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 D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 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 standard(s) 3, 5 and 6 A thorough assessment process plus an invitation to visit the Home, enables prospective residents to make an informed decision regarding their admission and gives them assurance that their needs will be met. EVIDENCE: A comprehensive assessment of each resident’s care needs is undertaken prior to their admission to the Home. The completed documentation is retained in the care records. One person who had recently moved into the Home explained that both she and members of her family had had the opportunity to visit Woolstrop before a final decision was made about admission. She had found the staff friendly and welcoming, and had been reassured to know that she would be able to bring in some of her own possessions to furnish her bedroom. Intermediate care is not provided in this Home. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 9 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 standard(s) 7, 8 and 9 The care planning and medication administration systems in place address the residents’ care needs appropriately and also ensure that the people living at Woolstrop are not put at any risk of potential errors. EVIDENCE: A full plan of care is prepared for each resident, based on an assessment of their specific needs. Records are also maintained of any required risk assessments, blood pressure, pulse and weight. All are reviewed each month and updated if appropriate. Comprehensive daily records give a clear indication of the resident’s progress. A speech therapist visited to advise on the care of one person; a district nurse came to treat another. Full records are maintained of any care given by healthcare professionals. Medications, including controlled drugs, are stored, administered and recorded correctly. Appropriate risk assessments are completed for those people wishing to self medicate. One person confirmed that she had locked storage in her bedroom to keep her medication securel. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 10 Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 11 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 standard(s) 12 and 13 Opportunities are provided for varied and stimulating activities and social contacts, as desired. EVIDENCE: A personal profile is prepared for each resident; this not only gives a picture of their background but also indicates any particular interests or hobbies. On the basis of this information and following discussions with the residents, a full programme of activities has been arranged. Some of these have been tailored to address the residents’ special care needs. All participation in activities is recorded. A group of residents really enjoyed a gentle game of quoits in which, despite some major physical difficulties, they were all able to take part. Relatives are given a friendly welcome at the Home; they are free to visit at any time to suit the resident. The daughter of one person said that she regarded the staff at Woolstrop as “good friends”. She is kept aware of her Mother’s progress and appreciates being able to take her Mother out for walks in the garden etcetera. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 12 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 standard(s) 16 and 17 A satisfactory complaints system enables service users and their families to feel assured that their views would be listened to and acted upon. Residents’ legal rights are protected. EVIDENCE: The Home has a written Complaints Procedure, which is readily available to residents, their visitors and members of staff working at Woolstrop House. The processes are explained in the Home’s brochure and are also outlined in the Statement of Purpose file, which is kept in the front hall. There have been no formal complaints in recent months. Residents have been included on the Electoral Register; two people chose to submit a postal vote at the recent Election. Information on obtaining Advocacy Support is advertised in the Home. None of the current residents have required this facility. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 25 and 26 Urgent plumbing work is required to ensure that residents live in an otherwise safe and comfortable environment. EVIDENCE: On the whole the Home is decorated and maintained to a reasonable standard although there are areas, which are now looking a little ‘tired’. Furniture in the communal rooms is sturdy but comfortable and appropriate to the needs of the elderly residents. The gardens are well stocked and easily accessible to the people living in the Home. Hot water for the Home is now stored at a safe temperature to prevent the development of Legionella but is still not distributed at safe temperatures. The Orders of St John Care Trust has obtained a quotation to install the equipment required to rectify this urgent health and safety requirement and has given assurances that the necessary work will be addressed shortly. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 14 The entire Home is fresh and clean. Laundry processes are addressed correctly. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Skill mix and staffing numbers are adequate to meet the needs of the residents living in the Home. Recruitment processes are in place to ensure the protection of residents living at Woolstrop House. EVIDENCE: There were forty residents living in the Home although one person had been hospitalised following a recent fall. In the morning, the Acting Manager, another trained nurse plus seven carers were in the Home to look after the people living there; one nurse and five carers were due to be on duty in the evening; with a nurse and two carers working at Woolstrop House overnight. Each of the residents who were spoken to felt that they were receiving good care at the Home. Inspection of the personnel records showed that careful recruitment procedures are followed when employing new members of staff. Excellent records are maintained of the interview processes and all the required employment checks are undertaken before the member of staff joins the team. Current application forms for prospective new employees do not request a full employment history, as must be obtained. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 36 and 38 Management systems are in place to ensure that the financial interests, and the health, safety and welfare of people using the service are safeguarded. EVIDENCE: The Acting Manager has submitted an application to be registered in the post. She has attended courses in recent months to ensure that she remains updated in clinical practise and is now waiting to commence the Registered Manager’s Award. The Administrator takes responsibility for the personal monies for over 50 of the residents; three were randomly selected for inspection. The money is maintained in individual secure storage and the records are audited every fortnight. Nevertheless, the records for one person were incorrect. This is now being addressed. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 17 Formal staff supervision arrangements are in place; full records are maintained of the processes. Line Managers have had training in conducting appraisal and supervision meetings. The majority of ‘Health and safety’ issues are addressed well at this home. Members of staff have access to all mandatory training; meticulous records are maintained to ensure that any outstanding training is addressed when required. All necessary maintenance of equipment is undertaken in a timely fashion. Environmental risk assessments have not yet been reviewed and updated to reflect the true situation in the home. Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x x x 1 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 x x x 2 3 x 2 Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 19 Yes Are there any outstanding requirements from the last inspection? 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 25 Regulation Regulation 23(2j and n) and Regulation 13(4) Schedule 2.6 Requirement Timescale for action By 31.8.05 2. 29 3. 35 4. 38 Equipment must be installed to ensure that hot water flows from the taps at a safe temperature (previous timescale 28.2.05 not met) Each employee must provide a By 31.8.05 full employment history plus a satisfactory explanation for any gaps in employment Schedule Accurate records of all By 31.8.05 4.9 transactions relating to service users’ monies must be maintained in the Home Regulation Environmental risk assessments By 31.8.05 13(4c) must be reviewed and updated to reflect the true situation in the home (previous timescale 31.1.05 not met 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 Good Practice Recommendations Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Woolstrop House D51_D03_s64586_Woolstrop House_v233508_050705_stage 4.doc Version 1.30 Page 21 - 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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