CARE HOMES FOR OLDER PEOPLE
The Woodlands Inkersall Green Staveley Chesterfield Derbyshire S43 3HB Lead Inspector
Rose Veale Unannounced Inspection 3rd January 2006 10:30 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.V275962.R01.S.doc Version 5.1 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.V275962.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Woodlands Address Inkersall Green Staveley Chesterfield Derbyshire S43 3HB 01246 348040 01246 348043 Not given 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) Derbyshire County Council 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.V275962.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th August 2005 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. The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced. There were 18 residents accommodated in the home on the day of the inspection, including 3 residents for short-term care. Residents and staff were spoken with during the inspection. Records were examined, including care records, staff files, and health and safety records. The manager had completed and returned a pre-inspection questionnaire prior to the inspection and this provided useful information. The manager was available and helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better:
Although there were sufficient staff hours provided, there were gaps identified by staff where there were fewer staff on duty at busy times. Staffing levels should be reviewed in consultation with residents and staff to ensure that staff are always available in sufficient numbers to meet all the needs of residents. The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 Page 6 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.V275962.R01.S.doc Version 5.1 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.V275962.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not assessed at this inspection. Of the key standards, standard 3 was assessed and met at the previous inspection and standard 6 does not apply to this service. The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 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 and 9 Care plans were clear, detailed, and regularly reviewed ensuring that all the assessed needs of residents were addressed. Residents’ safety and welfare were promoted and protected by the systems in place for the safe handling and administration of medication. EVIDENCE: The care records of 2 residents were examined. Each resident had a care plan which addressed all of their assessed needs. Care plans had been regularly reviewed and updated. The care records included details of the resident’s personal preferences regarding their daily routines. The home had recently introduced a personal profile with information about the resident’s family, interests, and work life. The care records were audited monthly by senior staff at the home. Staff spoken with were knowledgeable about the care needs and personal preferences of residents. Medication in the home was administered using the Boots Monitored Dose System and the pharmacist from Boots carried out quarterly audits at the home. Medication was securely stored. The Medication Administration Records, (MARs), seen were all correctly completed. Satisfactory records were
The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 Page 10 seen of the ordering and receipt of medication. All staff administering medication had received appropriate training. Each resident had a photograph with the MAR and a risk assessment regarding their ability to understand and take medication appropriately. There were also details of how the resident preferred to take medication and of when ‘as required’ medication should be considered. This was an example of good practice in the home that helped to ensure the safety and welfare of residents. It was noted that the temperatures of the medication fridge were not being recorded correctly. This was discussed with the manager and put right on the day of the inspection. The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 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): 14 and 15 Residents were encouraged and supported to exercise control and choice in their lives. Residents’ nutritional needs were well met with good quality, wholesome food in pleasant surroundings. EVIDENCE: Residents spoken with said they were able to follow their preferred daily routines. Care records contained details of residents’ preferred routines and their preferred name. One resident spoken with had been able to personalise their bedroom with photographs, pictures and furniture and was pleased that this was possible. Residents meetings were held regularly and residents were consulted on matters such as the décor of the home and the menu. Residents spoken with praised the quality of food and meals offered. One resident said the meals were ‘excellent’ and that there was always a choice. Staff spoken with said that the meals were mostly home-made with fresh ingredients. There was a varied menu which appeared well balanced. Residents were regularly consulted about the menus. The dining areas in the lounges were pleasant and bright. Care records included a nutritional assessment and information about residents’ food and drink preferences.
The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: These standards were not assessed at this inspection. Both of the key standards, 16 and 18, were assessed and met at the previous inspection. The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: Although these standards were not specifically assessed at this inspection, two requirements made at the previous inspection were followed up. The requirements were to make good the damaged areas in the ground floor bathroom and a ground floor bedroom. Both these areas had been redecorated and so the requirements had been met. A recommendation made at the previous inspection to provide lockable storage in residents’ rooms had also been met. It was noted that the staff toilet did not have disposable paper towels and liquid soap, (to help with infection control). This was put right on the day of the inspection. The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 Page 14 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 and 29 Generally, residents’ needs were met by the number of staff on duty. Good recruitment practices ensured that residents were safeguarded. EVIDENCE: The staffing rota was seen and staffing levels were discussed with residents, staff and the manager. Residents spoken with said that staff were busy but were usually available when needed. Staff spoken with said that the staffing levels could be improved by having three staff in total, two care assistants and one senior staff, on duty for the whole duration of the morning and afternoon shifts. The present staffing levels allowed for one care assistant and one senior member of staff on duty between 7am and 8am with a second care assistant coming on duty at 8am. Staff spoken with said this was a busy time and they felt that they could not always spend the time with residents that they really needed. There was also a period during the afternoon when there was one care assistant and one senior member of staff. Although this was a quieter time, staff said that an additional care assistant would allow more time for social activities. The home was trying to recruit an activities coordinator and meanwhile was using the hours available to provide a range of activities for residents. The files of two members of staff were examined. Both contained all the required information, including Criminal Records Bureau disclosures and references. The files were well organised and securely kept. Staff training
The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 Page 15 records were also seen. All members of staff had individual records of training, including induction training. The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 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 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): 35 and 38 Residents were safeguarded by the systems in place and the practices in the home. EVIDENCE: The records of residents’ personal money were examined. The records were clear and well kept with two signatures for all transactions. Each resident had a risk assessment completed regarding their ability to manage their own money and also their preferences regarding their personal money. The resident or their representative had signed this document. This was an example of good practice in the home, safeguarding residents and ensuring their preferences were respected. Residents’ personal money was kept securely in a safe. Health and safety records were examined, including the fire log book, the accident book, and risk assessments for the environment of the home and tasks carried out by staff. All the records seen were well kept and up to date.
The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 Page 17 Staff spoken with had a clear understanding of health and safety issues, for example, the correct moving and handling procedures for individual residents, and the importance of infection control measures. The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 Page 19 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. 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 residents and staff to ensure that staff are always available in sufficient numbers to meet the needs of residents. The Woodlands DS0000035775.V275962.R01.S.doc Version 5.1 Page 20 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
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