Inspection on 24/07/06 for The Woodlands

This inspection was carried out on 24th July 2006.

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

The inspector 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 25/08/05

The Woodlands 19/05/05

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 Woodlands, The 434 Penn Road Penn Wolverhampton West Midlands WV4 4DH Lead Inspector Mr Ian Harris Key Unannounced Inspection 24th July 2006 08:00 24/07/06 08:00 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 Woodlands, The DS0000030105.V297408.R02.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. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands, The Address 434 Penn Road Penn Wolverhampton West Midlands WV4 4DH 01902 341203 01902 337302 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) The Society of Friends Mrs Christine Carol Edmonds Care Home 38 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (29) of places Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th August 2005 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 been converted to provide an nine 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. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 5. hours. 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. 5 members of staff, 8 residents and 2 relatives were spoken to. It was noted that the fees range between, £341 to £476. for the main home and £417 to £424 for the annex On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. All the residents spoken to who could express themselves in a meaning full way expressed their satisfaction with the care they received and there were comments as follows “ the food is good here” “The staff are very kind” “ I like my room it used to be the masters room, this is a very beautiful home and the staff are good.” “I like the gardens and grounds”. What the service does well: Woodlands, continues to provide a high standard of care. The Care Manager and staff are to be commended on their efforts to encourage the residents to maintain their independence through social activities both within and outside the home. In particular the work that the home is carrying out through a designated member of staff to stimulate and motivate residents is to be commended. Observations during the inspection saw very attentive staff providing for the individual needs of the residents. The opportunity for residents to have a leisurely breakfast in their bedrooms is to be commended. Also the gardens grounds and summerhouse are a great asset to the residents, particularly this time of the year. The home has a very good staff- training programme, which all of the staff are involved in, this ensures that they are improving their knowledge and skills. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Woodlands, The DS0000030105.V297408.R02.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 Woodlands, The DS0000030105.V297408.R02.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): 1, 3 and 6 The home has a satisfactory admissions procedure ensuring the individual needs of the residents are fully met. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: All the residents who are funded by the Local Authority undergo a full multidisciplinary assessment prior to admission. The residents’ who are self funding are assessed by the Care Manager, using the homes assessment forms. Copies of the assessment, Care Plan and Reviews are on the residents’ files. The Four care plans inspected contained pre admission assessments of the persons needs, both from assessments by the home’s staff and other relevant professionals. It was noted that the residents terms and conditions/ contracts should be up-dated to include residents’ room numbers. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 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 the following standard(s): 7, 8, 9, and 10 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 resident’s 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. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Six residents case files were inspected and all contained 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. Medication is administered by means of a monitored dosage system. The Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 10 system is working well. The home receives good support from the local pharmacist who carries out a three monthly audit. All Senior Care Staff are trained in the system before they are allowed to administer medication. The home has comprehensive policies and procedures, which are an integral part of the homes staff induction programme. It was noted that the control drugs are not being stored in a double lock facility All residents have single rooms. No personal care interventions take place in communal areas. Observed practice on the day of inspection was appropriate and showed respect for the residents. Consultation with health care and social care professionals is carried out within the resident’s bedrooms. Visitors are able to meet residents in their bedrooms or the quiet room on the first floor offers that privacy when not being used. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 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 the following standard(s): !2, !3, 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 meals in the home are good offering both choice and variety and also catering for special dietary needs. The quality outcome in this area is excellent. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The staff at the home, encourage regular contact between residents and their relatives by inviting them to coffee mornings, parties, fetes and celebrations. It was noted that approximately 10 resident’s are regularly taken out by their relatives and 2 residents go out unaided. The residents and staff stated that the residents are consulted regarding the day-to-day running of the home through residents meetings and by feedback from their key-workers. 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. There have been outings to the theatre and a canal trip and garden centres. During the inspection many of the residents were delighted in telling Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 12 the inspector about the wonderful 60th anniversary celebration party they and their visitors had all enjoyed. The observations made, examination of menus and the comments received from the residents and their relatives confirmed that particular attention is given to the residents’ individual preferences. All of the comments made by residents regarding the quality, quantity and variety of food provided, that is provided were complimentary. It was noted that residents are able to have their breakfast in their bedrooms if they so wish. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 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 the following standard(s): 16 and 18 The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home has a good complaints procedure and all complaints are recorded in a, complains book. Residents and their families are given a copy, of the complaints procedure at admission and there are copies readily available in the office area. It was noted that no complaints have been recorded since the last inspection. However it is noted that in the pasted, complaints have been dealt with speedily and appropriately. 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 induction and N.V.Q. training, which the Staff undertake. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 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 the following standard(s): 19 and 26 The standard of the environment is good providing service users with a safe well-maintained environment to live in. The standard of cleanliness reflects the on-going cleaning schedule, which maintains this standard throughout the home. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: 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 been converted to provide an nine bedded unit for elderly mentally infirmed. The home is set in extensive grounds, which has a well- maintained formal garden. There is a good programme of refurbishment and redecoration within the home. The home is maintained to a high standard. Six residents bedrooms, have been redecorated and one room re-carpeted. The staff room has been redecorated and all the lead piping in the home has been replace. It was noted that all of Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 15 the recommendations by the Fire Prevention Officer have now been completed. It was also noted the en-suites in bedroom4,6,and seven and the corridors in the annex need redecorating. The home was found to be clean and tidy and free from odour. The home has good policies and procedures regarding infection control and all the staff have received training in food hygiene All staff appeared to be conscious of the dangers of cross infection. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 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 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): The home is well staffed with adequate numbers and skill mix of staff. The staff have a very good understanding of the residents support needs. The home has good policies and procedures regarding the recruitment of staff, which includes all the appropriate staff checks and references. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. 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 an acceptable procedure and has registered with the Social Care Association 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 programme of N.V.Q. training, which has now exceeded the minimum standard and most of the care staff have now completed N.V.Q. level 2 and a number of staff members are undergoing N.V.Q. level 3. Also the care staff have attended courses on Safe handling of medication, Dementia Awareness, Moving and lifting, First Aid, Food Hygiene, Infection Control, Falls Prevention, Activities Training, Fire Prevention and Bereavement and Loss. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 17 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, and 38 The home is a well managed, where service users interests and welfare is promoted. The home is operating a good system to assist residents with the safe handling and keeping of their personal finances and good records are being kept of all transactions made. All the general records that was inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The Care Manager has been in post for a good number of years and is qualified in both practice and management and has considerable experience in caring for older people, in a residential home setting. There are clear lines of Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 18 accountability within the home and the manager is well supported by the management committee. Observations made and discussions with residents and staff indcated that the Care Manager is very approachable and operates an open door policy and is proactive in meeting all the residents on a daily basis. The staff and residents who could express themselves stated that they are happy to approach the Care Manager with any problems they might have and are confident that they will be resolved. The routines and activities within the home are flexible and built around the needs of the residents. There was also evidence to show that staff consult with the residents regarding the choice of meals and activities within the home. There are regular resident meetings where residents are consulted about menus and entertainment etc. Also the Key-Worker system in operation is designed to ensure residents’ wishes are responded to. There is evidence on file of quality assurance questionnaires have been used to obtain feedback on the service provided from residents and relatives. All the records and administrative procedures within the home that were, inspected were found to be well ordered and 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 on these issues. All safety equipment is check and well maintained. Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 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 3 X 3 X 3 X X 3 Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 20 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 OP1 Regulation 5 (1) © Requirement Timescale for action 01/09/06 2. OP 19 23 3 OP9 12 (3) The registered person must revise all of the terms and conditions of residence to include room numbers. The registered person must 01/10/06 ensure that the en-suites in rooms 4,6.and 7 and the corridor in the annex are re-decorated. The registered person must 01/09/06 ensure that all controlled drugs are stored in a double lockable cabinet. 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 Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street 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. Extracts may not be used or reproduced without the express permission of CSCI Woodlands, The DS0000030105.V297408.R02.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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