Inspection on 09/08/05 for The Woodlands

This inspection was carried out on 9th August 2005.

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

The inspector 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 01/08/06

The Woodlands 03/01/06

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 Derbyshire S43 3HB Lead Inspector Rose Veale Unannounced Inspection 09 August 2005 at 10:15 am 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 C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Woodlands Address Inkersall Green, Staveley, Chesterfield, Derbyshire, S43 3HB 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) 01629 580000 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 C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10/03/2005 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 C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 4 hours on one day. There were 15 permanent residents and 1 resident for short-term care in the home on the day of the inspection. Residents, staff and visitors were spoken with during the inspection. A tour of the building was undertaken. The care records of three residents were examined, plus other records relating to the staffing and management of the home. The manager and deputy manager were available and helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Some attention to the décor of a bathroom and one of the bedrooms was required. A shower room would be improved by the removal of shelves which are no longer in use. These improvements would make a more pleasant environment for residents. Lockable storage suitable for money and personal valuables should be provided in residents’ rooms so that residents could be sure their possessions were secure. Consideration should be given to increasing staff hours to allow for more help around teatime to improve the service offered to residents. The post of activities coordinator should be filled as soon as possible to ensure that residents’ social needs are fully met. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 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 C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 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 C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4 and 5 The assessment process in place and the practice of encouraging day assessment visits ensured that residents could make an informed choice about moving to the home. EVIDENCE: The care files of three residents were examined. All the files contained assessment information from care managers. There was also the assessment carried out by the home when the resident had visited for the day prior to admission and assessments by the home soon after admission. It was a requirement at the last inspection that the manager of the home should carry out assessments prior to admission for all self-funding residents. The manager explained that there are no self-funding residents in the home at present, and that the procedure would be to invite the prospective resident for a day assessment in the home prior to any decision being made about admission. One of the files of a recently admitted resident contained a copy of a letter to the resident stating that the home was able to meet their needs. It was a requirement at the last inspection that this information should be included in residents’ files. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 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 10 Residents’ health and personal care needs appeared to be fully met, with good liaison with other healthcare professionals and evidence of respecting residents’ privacy and dignity. EVIDENCE: The care files seen all contained care plans detailing the action required by staff to meet the needs of residents. The care plans were clear and detailed and included residents’ preferences regarding their daily routines. The care plans had all been reviewed monthly by the keyworkers. In two of the files seen the residents had been involved in the care plans and reviews, evidenced by their signatures. The manager had reviewed the care files at least monthly, as required at the last inspection. Information had been included in the care files to meet requirements made at the last inspection, including the date of admission, the residents’ preferred name, the name of the care manager involved, and an indication of the residents’ ability to make choices. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 10 The care files seen all contained records of the input of healthcare professionals, such as GP, District Nurse, chiropodist, dentist and optician. The manager said that all residents were registered with a local GP. It was clear from the files seen that residents’ health needs were monitored and appropriate action taken. For example, one file contained a tissue viability assessment by the home which indicated that the resident was at high risk of developing pressure sores. There was a record that the home had contacted the District Nurse for advice and support and a record of the subsequent input. Another file contained a nutritional assessment and weight record which showed that the resident had recently lost weight. This was followed up by the home with a request to the GP to prescribe food supplements and to reassess the resident. Although Standard 9 was not specifically assessed at this inspection, the Medication Administration Records, (MARs), were seen for the three residents whose care records were examined. The MARs were generally satisfactory and included a record of when cream was administered to residents, as required at the last inspection. There were some handwritten entries on the MARs which had not been signed by the member of staff making the entry, or counter signed by another member of staff. Residents spoken with said that they felt staff respected their privacy and dignity. During the inspection, staff were observed to knock on residents’ bedroom doors before entering and to address residents in a respectful way. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 13 There was a programme of activities at the home to meet residents’ social needs. However, the current lack of an activities coordinator could have a negative effect on the range and frequency of activities available to residents. Routines at the home were flexible to meet residents’ needs and preferences. EVIDENCE: Residents’ preferences regarding their daily routines were recorded in their care files. A resident spoken with felt that daily routines were flexible enough to meet needs and preferences. A social / family history was obtained for each resident so that staff were aware of residents’ previous life experiences and family ties. Records were kept of activities undertaken by residents and these included bingo, trips out, a ‘beer and chips’ night, entertainers, quizzes, and manicures. The manager explained that the activities coordinator had recently left and it was hoped that a replacement could be recruited soon. The hours allowed for the activities coordinator were being used, but sometimes to cover shortages in care hours. Staff spoken with felt that the care staff did not always have enough time to carry out activities with residents. Residents spoken with said they had enjoyed recent trips out. Residents meetings were held regularly and activities were discussed. There was an open visiting policy at the home. Residents spoken with said they could see visitors in private if they wished. Visitors spoken with said they were always made welcome. There was a quiet lounge in the home with tea The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 12 and coffee making facilities for residents and their visitors. There was also a small fridge provided in the main lounge for residents or visitors to keep cold drinks. The home was situated very close to the centre of the village so the residents could easily access local shops and facilities. The manager said that residents had used a local social club and the local hairdresser. A church service was held in the home every two weeks. Local community groups had visited the home, such as the Cubs and Beavers and the Women’s Club. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 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 policies and procedures in the home, and staff awareness and attitudes, ensured that residents were protected from abuse, and that residents and their representatives could be sure that their complaints were taken seriously. EVIDENCE: It was a requirement at the last inspection that the manager should record verbal complaints in the home’s complaints book. This was seen and showed that verbal complaints were being recorded. The book contained details of the complaint, the action taken and the outcome. There had been no formal, written complaints since the last inspection. Two residents spoken with were aware of the complaints procedure and said they would be happy to take up any concerns with the manager. The home used the Derbyshire County Council’s multi-agency procedures for the protection of vulnerable adults. Staff training included adult protection awareness and procedures. Staff spoken with were aware of the procedures and said they would be able to go to the manager with any concerns. The home had recently introduced financial risk assessments to ensure that residents were protected from financial abuse. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 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, 21, 24 and 26 The home was clean, comfortable and generally well maintained, providing a pleasant environment for residents. EVIDENCE: The home was generally well maintained. It was a requirement at the last inspection that the exterior of the home needed redecoration and this work was being carried out at the time of this inspection. The gardens were well maintained and accessible to residents. Residents and visitors were sitting outside on the day of the inspection enjoying the sunny weather. The ground floor bathroom had been pleasantly decorated but there were some areas where the walls had been knocked which needed repainting. There was damage to the door and the inside wall of a ground floor room which required repair. Otherwise, the home was in good decorative order, bright and pleasant throughout. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 15 There were sufficient, accessible toilets for residents to use with grab rails and raised toilet seats available. There were two baths for residents to use, both adapted for people with limited mobility. There was a shower with integral seat. The manager said the shower wasn’t used as often as the baths because of residents’ preferences. The shower room had open shelves which had previously been used for storage. These were no longer in use and should be removed to create a more pleasant room. Residents spoken with said they were happy with their rooms. One resident was pleased with a large room with access to a patio area. The rooms seen were well decorated, comfortably furnished and personalised with residents’ possessions. None of the rooms seen provided a lockable storage space suitable for personal money and valuables. All the rooms seen had lockable doors. It was noted in the care records seen that residents had been asked about a key for their own rooms. The manager said that only one resident had requested a key. Residents spoken with did not want a key to their rooms. The laundry in the home was spacious and well equipped. The home was clean on the day of the inspection and was free from unpleasant odours. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 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 and 30 There were sufficient staff to meet the needs of residents and there was a good programme of staff training to enable them to carry out their roles effectively. EVIDENCE: The staffing rota was seen and showed that there were sufficient staff on duty. The manager said that the home was trying to recruit for two vacant posts and that it could be difficult to cover staff sickness and holidays. It was commented that the home would benefit from additional kitchen help at tea time so that care staff could be available to assist with the care of residents. Staff training records were seen and showed that most of the care assistants working at the home had NVQ Level 2 in Care. The manager estimated that 95 of care assistants had achieved NVQ Level 2 or above. The training records showed a range of training undertaken by staff, including fire safety, moving and handling, first aid, basic food hygiene, communication skills, and anti-discrimination training. Staff spoken with said training was a high priority at the home. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 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 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, 33, 34, 36 and 37 The home was well run with the best interests of residents in mind, and with good leadership, guidance and support for staff, as demonstrated by the home’s annual plan and quality assurance programme. EVIDENCE: The manager had been in post for several years and had achieved NVQ Level 4 in care and management. There was clearly an open and effective rapport between the manager and staff in the home. Staff felt that the manager and deputies were ‘hands on’ and easy to talk to. Residents and visitors appeared to have a good relationship with the manager. It was a requirement at the last inspection that the providers must arrange for a monthly unannounced visit to the home by the senior line manager, with a report on findings. Records seen showed that these visits were taking place as required. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 18 There was a quality assurance system in place in the home with annual questionnaires for residents, visitors and staff and a report of the findings. Other questionnaires were used by the senior line manager during monthly visits. Care reviews and residents meetings also provided information for quality assurance. Records were seen of the home’s annual business plan which included budget figures for the home. The plan clearly detailed the proposals for the home, the action to be taken to achieve these and a recent review. Records were seen of staff supervision sessions. Staff spoken with confirmed that they were receiving supervision every 6 to 8 weeks and that they found this useful. The manager received regular supervision from her line manager. Records kept in the home were stored securely. The records seen were in good order, well organised and up to date. It was a requirement at the last inspection that records must be kept of the meals provided for each residents. This record was seen and was satisfactory. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x 3 x x 2 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 3 x 3 3 x The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 20 NO 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 9 Regulation 13(2) Requirement Handwritten entries on Medication Administration Records must be signed by the person making the entry and countersigned by another member of staff Damaged areas on the walls of the ground floor bathroom must be made good Damaged areas to the door and wall of Room 2 must be made good Timescale for action 30/09/05 2. 3. 4. 19 19 23(2)(b) 23(2)(b) 31/10/05 31/10/05 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. 2. 3. Refer to Standard 21 24 27 Good Practice Recommendations Removal of the shelves from shower room would make it more pleasant for residents to use Residents should be provided with lockable storage in their rooms, suitable for money and personal valuables Consideration should be given to increasing staffing hours to allow for additional help at teatime. The Woodlands C52 C02 S35775 The Woodlands V243474 090805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection South Point 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. 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