Inspection on 01/08/06 for The Woodlands

This inspection was carried out on 1st August 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 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

The Woodlands 03/01/06

The Woodlands 09/08/05

The Woodlands 10/03/05

The Woodlands 16/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Woodlands Inkersall Green Staveley Chesterfield Derbyshire S43 3HB Lead Inspector Denise Bate Unannounced Inspection 1st August 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 The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 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. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Woodlands Address Inkersall Green Staveley Chesterfield Derbyshire S43 3HB 01246 348040 01246 348043 Not given www.derbyshire.gov.uk Derbyshire County Council 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) Maxine Beer Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 Brief Description of the Service: The Woodlands is situated in the village of Inkersall on the outskirts of Chesterfield. The home is near to local facilities, including shops, a social club, pub, post office and public transport. The home is owned by Derbyshire County Council and provides personal care for up to 18 residents aged 65 years or over. The home provides day assessment for prospective residents and short term care. All residents are accommodated in single rooms, although some rooms can be arranged as doubles for those wishing to share. There are two lounge / dining rooms, a quiet room and a smoking lounge. There are garden areas surrounding the home with a private, secure patio to the rear. Fees are £364 per week for permanent service users, with a range of prices for short term care service users. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven hours. During the inspection eight service users, two relatives, and two staff members were spoken with. The manager and two deputy managers were present during the inspection and provided assistance and information. Written information was provided by the manager on the day of inspection. A number of records were examined, including risk assessments and care plans, health and safety documentation, staff files, medication records and Regulation 26 visit records. Three service users were case tracked. A tour of the building took place. What the service does well: What has improved since the last inspection? What they could do better: As noted at the previous inspection, there continue to be gaps in the staffing levels where there is only one member of care staff on duty. The home is not The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 6 currently providing the number of domestic hours specified in the Statement of Purpose. Staff are committed and are ensuring that standards are maintained by taking on additional duties, part time staff are working some extra hours, and outside staff are covering some shifts. In the longer term it may benefit both staff and service users to have vacancies filled on a permanent basis. A quality assurance exercise had been carried out, but the results were not available on the day of inspection. It is understood that they will be available in the near future for the manager to draw up a plan under ‘Your Views, Our Actions’. 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. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 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 The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home have a system for assessing service users’ needs to ensure that the care provided can meet service users’ needs appropriately. EVIDENCE: Assessments are carried out in the community by social workers and care managers and copies were seen on care planning documentation. Potential new residents are invited to spend a day at the home with their relatives, and this visit is used to verify assessment information, provide the service user with information and choice, and undertake any further assessments. Copies of the visit assessments were seen on the file of a case tracked short term care user, as were copies of evaluation of periods of short term care undertaken. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate care so standard 6 does not apply. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 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, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans relating to personal and social care needs of service users are completed in sufficient detail to direct and inform staff on how individual needs should be met. Service users are encouraged and supported to be independent and to exercise choice in all aspects of the home and are treated with dignity and respect. This contributes to the enhancement of service users’ everyday lives. EVIDENCE: All case tracked service users had personal development plans, daily logs, assessment forms for nutrition and tissue viability, risk assessments, monthly summaries, and monitoring forms e.g. heath professional visits, etc. Service users had signed documentation indicating that care plans had been discussed with them, and there was evidence of regular reviews. Information was The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 11 recorded in detailed daily logs. In some instances the personal service plan was not updated in detail where a service users needs had changed. Reviews happened on a regular basis and there was evidence of consultation with service users and relatives over care planning matters. Some service user information is kept in other places, e.g. there is a detailed activities folder that has information about the interests and preferences of all service users. Work has also been done to obtain personal and social histories of service users. Service users’ health needs are recorded monitoring documents within the care planning documentation. It was reported that a good relationship exists with local GPs and with District Nurses and the local Community Psychiatric Nurses. The administration of medication was inspected and records found to be satisfactory. The inspector was informed that the pharmacist had visited recently and carried out a satisfactory inventory of the home’s medication storage and administration, and this report was made available. The home has a separate medication room with the medicines trolly, fridge and controlled medication cupboard. Derbyshire County Council have recently introduced a new medicines code for their residential homes and staff were in the process of studying this document to ensure that their practices complied. Service users spoke very positively about staff and said they were treated with dignity and respect. One service user commented that she was ‘very happy’. Confirmation was provided by both relatives and service users that they are given choice and are able to follow their own routines, and several examples were given. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 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, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided that suit the expressed preferences of service users. Regular outside contacts are encouraged and supported. This assists in contributing to a pleasant atmosphere and the overall high level of satisfaction for service users. Dietary needs of service users are catered for with a balanced and varied selection of food available that meets service users’ tastes and choices. EVIDENCE: The home have recently appointed a designated member of staff to run activities, but they have not yet taken up post. Regular activities include quizzes, outings, in house entertainment, bingo and regular religious services. Details of forthcoming events and other information useful to service users and relatives/friends are displayed in the main entrance area. As mentioned previously, individual work has been done with each service user to identify The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 13 preferences and interests. An outing for service users to Peak Rail took place on the day of inspection. Service users and relatives indicated that they feel staff are approachable and any problems can be discussed with them or with one of the managers. All indicated that they are able to exercise choice about aspects of their daily lives. The home have contacts with the local community groups, including the local church and services are held at the home regularly. The vicar visited on the day of inspection. Relatives and friends of service users are encouraged to become involved in the home in a variety of ways. It was confirmed that visitors to the home are welcomed. Most service users have regular contact with relatives and friends and some go out on a regular basis. Most service users live locally and reflect the cultural background of the local area. Service users and relatives spoken to were complimentary about the standard of catering, and the choice of menus that are available. One service user said that she enjoyed the ‘good dinners’ and another said she especially enjoyed having a cooked breakfast. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place which promote the Safeguarding Adults from abuse. A clear and accessible complaints procedure is in place ensuring service users can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: There is a corporate complaints procedure in place, although most relatives and service users prefer to raise issues on a more informal basis. The manager and staff are viewed as approachable and responsive. There have been several formal complaints recorded, some of which relate to the activities of members of the public in the vicinity of the home. Other completed related to minor issues and had been dealt with appropriately. There is also a book for recording compliments, and this provided positive feedback on the good level of services provided. Derbyshire County Council has clear procedures for dealing with the safety of service users and safeguarding them from harm. Staff spoken to had had training in the protection of vulnerable adults and showed an awareness of adult protection issues and would pass any concerns on to their line manager. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 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, 21, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment within the home is generally well maintained and provides service users with an attractive and homely place to live. EVIDENCE: The building provides service users with a comfortable and homely place to live with a variety of communal spaces situated in the front area of the building offering a choice of seating arrangements for service users. The dining areas are pleasant and situated in the lounges. The building has continued to be generally maintained to a reasonable standard. There is a rolling programme for maintenance and redecoration. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 16 Some toilets and bathrooms were seen and found to be satisfactory, apart from the ground floor bathroom where the bath is rather worn and the upstairs toilets which have some staining. Service users said they were satisfied with their bedrooms, and several bedrooms were seen. These were pleasant and had been personalised. Some of the bedrooms were extremely spacious having previously been shared occupancy. There is a garden area where service users can sit in fine weather, although the recent very hot weather had dried up the lawn and some plants. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 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): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which generally meet the dependency needs of service users currently accommodated within the home. EVIDENCE: The staff rotas were discussed and found to provide adequate staffing to meet service users’ needs at the current time. However, there are a number of problems. Staff are often very busy, and there are periods in each day where there is only one member of care staff on duty. This means that staff cannot spend as much time as service users might need to manage all care needs comfortably and would present problems if service user dependency increased, e.g. hoisting requiring two to transfer. At the present time the home does not have sufficient domestic staff to meet the number of domestic hours stipulated in the Statement of Purpose. Part time staff are working extra hours to cover extra shifts and in the longer term this may be to the detriment of both staff and service users. Some staff employed by other homes or home helps sometimes cover shifts at the home, but induction always takes place prior to them commencing duties, e.g. on fire The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 18 safety. The inspector was informed that the home are not able to advertise for permanent staff at present, although they are able to advertise for contract staff. Where new staff are appointed there is often a delay before they can start their induction as the results of CRB checks are awaited. The inspector was informed that extra money for staffing was available if service user dependencies increased. Continued vigilance will be needed to ensure that staffing levels continue to meet service users’ needs as current service users become more dependent. It is anticipated that staffing rotas will be looked at again at future inspections. The manager said that staff worked well as a team and were helpful, flexible and supportive. Staff spoken to were responsible, committed and competent. There is a team approach to work. Staff said they feel supported by both their colleagues and their managers, and felt that they were offered good training opportunities. Derbyshire County Council has made a commitment to staff training and over 50 of staff are trained to NVQ2 or above. Staff said that the manager encourages staff to take up training opportunities and made available any new policies and procedures guidance. Not all staff files seen had evidence of CRB checks or application forms, although these were available centrally. Derbyshire County Council has a thorough and detailed recruitment and selection procedure. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 19 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, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced and staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is run in the best interests of service users. EVIDENCE: Service users, relatives and staff spoke positively about the manager and the management team. There is an ‘open door’ policy and several service users and relatives called into the office on the day of inspection, as well as health and other professionals who were visiting the home. There is good communication between staff and effective handover arrangements. Relatives said that they were always informed of any matters pertaining to service users well being. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 20 The unit manager has overall responsibility for the planning and development of the home and deputies have responsibility for daily operations and have their own areas to manage. One member of staff has recently moved to another home to take up a temporary management contract. The home is visited regularly by a representative of the registered person and Regulation 26 visit reports were made available to the inspector. These indicated that matters of day to day management are dealt with, and service users and staff spoken to on a regular basis. There had been a quality assurance exercise but the results of the survey have not yet been made available to the home or to service users. The inspector was informed that this will be happening in the near future. Residents meetings are held. Service users monies are kept in the safe and manual records kept. The records were made available and were satisfactory. Staff confirmed that they have regular supervision. One member of staff was undertaking management induction training on the day of inspection. Information on maintenance and health and safety records was provided by the manager and indicates that, apart from the electrical hard wiring certificate and gas safety certificate, matters pertaining to maintenance and health and safety are satisfactory. The electrical hard wiring certificate indicates that some electrical work needs to be carried out. A certificate of gas safety was not available on the day of inspection, but the inspector was informed that one is available centrally. Standards of cleanliness were satisfactory on the day of inspection. As previously noted, the home is not currently meeting its allocated domestic hours and a recommendation has been made on this matter. Infection control was discussed with the manager in relation to a number of specific notifications. The home had a copy of the most recent infection control advice, which is being widely made available to staff. The manager has requested specific training in this area and it is understood this will take place in September 2006. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 21 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 X 2 X X 3 X 3 STAFFING Standard No Score 27 2 28 3 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 2 The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations Staffing levels should be reviewed in consultation with service users and staff to ensure that staff are always available in sufficient numbers to meet the needs of residents. Consideration should be given to upgrading or improving the downstairs bathroom and the upstairs toilets. Domestic hours provided by the home should be as specified in the Statement of Purpose. Copies of application forms and evidence of CRB checks having been done should be available on all staff files. The results of the quality assurance questionnaire should be made available to service users and a plan prepared to action any improvements needed. A satisfactory programme for carrying out work identified on the recently electrical hard wiring certificate should be drawn up. A copy of the gas safety certificate should be kept at the DS0000035775.V305991.R01.S.doc Version 5.2 Page 23 2 3 4 5 6 7 OP21 OP27 OP29 OP33 OP38 OP38 The Woodlands home. The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 The Woodlands DS0000035775.V305991.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!