Inspection on 19/05/05 for The Woodlands

This inspection was carried out on 19th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

The Woodlands 24/07/06

The Woodlands 25/08/05

The Woodlands 21/09/04

The Woodlands 08/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Woodlands 434 Penn Road Penn Wolverhampton WV4 4DH Lead Inspector Ian Harris Unannounced 19 May 2005 09.00 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. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Woodlands Address 434 Penn Road, Penn, Wolverhampton, WV4 4DH 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) 01902 341203 01902 337302 The Society of Friends Christine Edmods Care Home 37 Category(ies) of Old Age (29) registration, with number Dementia (8) of places The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21/09/2004 Brief Description of the Service: The home is a listed building with great charm. It consists of a main building with three floors and a two- storey annex. The annex is linked to the main building by a covered walkway. The annex has recently been refurbished and converted to provide an eight bedded unit for elderly mentally infirmed. The home is set in extensive grounds, which has a well- maintained formal garden. The home is situated approximately two and a half miles from Wolverhampton City Centre. A local bus service stops at the end of the homes drive and there are amenities a few hundred yards from the home. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 hours. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report. The fullest co-operation was given to the inspection officer by the Care Manager staff and residents. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 11 of the 33 staff were on duty, and 10 of the 36 residents were spoken to On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable. The homely environment and the attentive staff have helped to provide a warm, comfortable, stimulating and secure environment for the residents. What the service does well: What has improved since the last inspection? The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 6 The home has a very good maintenance and refurbishment programme and an on site handyman. Internally 6 residents’ bedrooms have been redecorated and re-carpeted and the kitchen and storerooms also have been redecorated. The care Manager has gained her Registered Managers Award and another Senior Assistant has successfully completed the N.V.Q. 4 in care. 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. The Woodlands E56 s30105 The Woodlands V226227 190505 UI 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 The Woodlands E56 s30105 The Woodlands V226227 190505 UI 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) 1,5, and 6 The home provides good clear accurate information regarding the service provided, which is available in the office in the home. The home is proactive in encouraging residents’ family and friends to keep in contact and visit the home. The home does not provide intermediate care. EVIDENCE: The statement of purpose and the service user’s guide are available in the office. Also a copy of the last inspection report is available to anyone interested. The home has a good brochure that is given to prospective residents and their families. It was noted the staff at the home are proactive in inviting prospective residents and their families to visit the home and ask any questions they may have regarding the services provided in order to make an informed choice. All residents are encouraged to visit the home prior to admission. However it was noted that on occasions the visits are declined and relatives visit the home on behalf of the prospective resident prior to admission. A trial period is included in the statement of terms and conditions of residence and the homes contracts and is discussed with the residents and their relatives at the time of admission. The home does not provide intermediate care. The Woodlands E56 s30105 The Woodlands V226227 190505 UI 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 Each resident has a comprehensive, individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that residents’ health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements being in place to ensure resident’s medication needs are met EVIDENCE: The home provides a comprehensive Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the care Plans are being carried out and reviewed on a monthly basis. The home is well supported by local G. P. s. and all of the paramedical services. Wherever possible, the residents are encouraged to retain their own G. P s, Opticians, and Dentists. It was noted that if the resident has moved out of their area the Care Manager ensures that, these services are provided by local practitioners. The records indicate that resident’s medical needs are being met. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 10 Medication is administered by means of a monitored dosage system, which is supplied by the local pharmacist. The system appears to be working very well. The home receives good support from the local pharmacist who does a three monthly audit of the homes medication. All care Senior Staff have been trained to use the system before they are allowed to administer medication. The home has very good policies and procedures, which are used as an integral part of the staff induction programme. The Woodlands E56 s30105 The Woodlands V226227 190505 UI 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) 12,14, and 15 The home provides a stimulating experience for the residents where they are encouraged to maintain their independence as much as possible The home provides a good range of social activities within and outside the home designed to the capabilities of the residents The residents are regularly consulted about their care and the running of the home and Key-workers assist them to make informed choices. The meals in the home are good offering both choice and variety and also catering for special dietary needs EVIDENCE: The routines and activities within the home are flexible and are built around the needs of the residents. There is also evidence to show, that staff consult the residents regarding the choice of meals and activities within and outside of the home. There are regular residents meetings where issues regarding menus and outings are discussed. The key-workers also identify interests that the residents wish to pursue. A regular programme of musical evenings, Art and Craft sessions, board- games and poetry readings is organised within the home. Outings to the theatre, garden centres, church flower festival and a canal trip have been arranged. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 12 Observations made, examination of menus and the comments received from the residents and their relatives confirmed that particular attention is given to the resident’s individual preferences. Comments made by residents regarding the quality, quantity and variety of food provided were highly complimentary. It was also noted that most of the residents are served breakfast in their bedrooms. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 13 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 18 The home has a good complaints procedure with some evidence that resident’s views are listened to and acted upon. The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy and the staff have a good understanding of their responsibilities. EVIDENCE: The home has a very good complaints procedure, which ensures complaints are dealt with promptly and all complains are recorded in a complaints book. Residents and their families are given a copy of the complains procedure at admission and there are copies readily available in the reception area. It was note that no complaints have been recorded since the last inspection. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which includes, a WhistleBlowing policy. These issues are also covered in the N.V.Q. training, which the Staff, are undertaking. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 14 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) 19,20,23,24, and 26 The standard of the environment within the home and the garden is very high providing the residents with a very attractive, comfortable, homely and safe place to live. The home was found to be clean tidy and free of unpleasant odour. EVIDENCE: The home has been established for 60 years and has undergone alterations in order to provide appropriate accommodation for older people. The coach house has been completely refurbished to provide a special unit for people suffering from Dementia. The home is maintained to a very high standard as is the gardens and grounds and provides a very comfortable homely and safe atmosphere. It was noted that 6 residents’ bedrooms have been redecorated and re-carpeted, and the kitchen and storerooms have also been redecorated. It was also noted that all the bedrooms have been personalised with the resident’s own personal possessions. This gives the appearance of a very comfortable environment. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 15 The home is furnished to a high standard throughout. All the bedrooms are well furnished, most have some items of the residents’ own furniture, close attention has been paid to detail. The home offers excellent facilities and communal space. There is a choice of lounges and sitting areas within the home that are decorated and furnished to a very high standard. All the shared spaces within the home provide a warm, friendly, safe and comfortable environment. The home has extensive well kept grounds that contains a summer house The home has very good hygiene and infection control policies and most of the care and catering staff have undergone Food Hygiene and infection control training .The domestic staff have undergone C.O.S.H.H. training. All staff are conscious of the risks of cross infection. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 16 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) 27,28,29, and 30 The home is well staffed with adequate numbers and skill mix of staff. The staff have a very good understanding of the resident’s support needs this is evident from the positive relationships which have been formed between staff and residents. The home has good policies and procedures regarding the recruitment of staff, which includes all the appropriate checks and references. There is a good training programme in place that ensures that the staff are competent to do their job. EVIDENCE: The inspection of staff rotas and discussions with staff indicated that the home is well staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. The home operates a good recruitment procedure and has registered with the Criminal Records bureau in order to complete the appropriate checks on staff. There was evidence within the home that all the checks are being carried out. All staff, at the home, are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has a very good programme of N.V.Q. training and 80 of the care staff have achieved N.V.Q. level 2 and all senior staff have completed N.V.Q.level3. Also the care staff have attended courses on Safe handling of medication, Infection control, Dementia care, and Moving and lifting. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 17 The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 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 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) 31,32,37, and 38 The manager has very good leadership skills and has a clear development plan and vision for the home, which she has effectively communicated to the residents, staff and relatives. The manager is well supported by her line manager and demonstrates an awareness of her roles and responsibilities. All the records that were inspected, were found to be well maintained. The home has good policies and procedures regarding Health and safety and the care manager and staff demonstrated that they are aware of their responsibilities to promote Health and safety and protect the residents. EVIDENCE: The Care Manager has considerable experience in caring for older people, in residential home settings and has also completed the Registered Managers Award. There are clear lines of accountability within the home and the Care Manager has regular supervision meetings with her line manager. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 19 Observations made and discussions with residents and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residents stated that they are happy to approach the Care Manager with any problems they might have. All the records and administrative procedures within the home that were inspected, were found to be well ordered and well maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training. Fire fighting equipment is well maintained and the systems are regularly checked. In regards to any accidents, they are minimal and are all recorded in an appropriate record book. The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x x 3 3 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 4 13 x 14 3 15 4 COMPLAINTS AND PROTECTION 3 x x x 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 4 x x x x 3 3 The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 21 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 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 Good Practice Recommendations The Woodlands E56 s30105 The Woodlands V226227 190505 UI Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2nd Floor, St Davids Court Union St Wolverhampton WV1 3JE 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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