Inspection on 11/07/05 for WCS - Woodside

This inspection was carried out on 11th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

WCS - Woodside 30/06/09

WCS - Woodside 07/07/07

WCS - Woodside 12/09/06

WCS - Woodside 01/03/06

WCS - Woodside 02/03/05

WCS - Woodside 18/06/04

WCS - Woodside 03/03/04

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE WCS - Woodside Spinney Hill Warwick Warwickshire CV34 5SP Lead Inspector Louise Thompson Unannounced 11 July 2005 09:20 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. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service WCS - Woodside Address Spinney Hill Warwick Warwickshire CV34 5SP 01926 429508 01926 498848 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) Warwickshire Care Services Limited Mrs Patricia B Ashwell Care Home 38 Category(ies) of Dementia - over 65 - (8) registration, with number Old Age - (30) of places WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 02 March 2005 Brief Description of the Service: Woodside care home is managed by Warwickshire Care Services Ltd who has managed the home since it transferred, along with a number of other homes providing care, from Warwickshire County Council in 1992. Warwickshire Care Services Ltd is a voluntary sector organisation.Woodside is registered as a care home providing personal care to 38 older people; this includes a registration for the care of 8 older people with dementia. The dementia unit is situated on the ground floor. The first and second floors can accommodate 15 and 15 service users respectively. Each floor has a lounge and dining area, which have been fitted with kitchenettes. On each floor there is also one bathroom, and a shower room is provided upon both the first and second floors. All bedrooms are single rooms, none have en-suite facilities. A passenger lift to each floor, and ramps leading to outside areas, ensure easy access to all areas of the home. The home is situated on the outskirts of Warwick, within a housing estate. Close by is a small parade of shops, including a post office, newsagent and general store. There is also a local pub. Both Warwick and Leamington Spa’s main shopping centres are within a 5-10 minute bus journey. The bus stop is directly outside the home. Woodside is a non-smoking home. Service users, representatives and staff are permitted to smoke outside the building. Woodside has a garden area to the rear and a secure garden leading off the dementia care unit. There is limited parking space for staff and visitors to the rear of the home. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day between the hours of 9.20 am and 5.10pm. This was the first visit for this inspection year. Staff co operated fully with the inspection. The registered manager was present throughout the inspection. The inspection process involved a tour of the home, talking with the manager, examining records and care plans, observation of care practices along with discussions with residents, staff and three relatives who visiting on the day of the inspection. What the service does well: 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. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 6 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 WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 7 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) These standards were not assessed as part of this inspection. EVIDENCE: WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 8 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, 9, and 10 Care plans require review to provide the staff with the necessary information to meet individual residents needs. Health needs of residents are met with evidence of liaison with health and social care professionals on a regular basis. Some progress has been made with arrangements for management and administration of medication. Personal support is offered in such a way as to maintain residents’ privacy and dignity. EVIDENCE: The home has recently introduced a comprehensive new care planning and quality management system. The records of four residents including one on respite care were observed during this inspection. The quality of the assessment and care plans differed, with assessments and care plans of two of the files viewed being more specific. Records for the respite resident were incomplete and there were no care plans available. Good risk assessments were observed with ongoing monthly reviews of these, which enable staff to monitor changing dependency levels. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 9 Care plans seen were not up to date for some aspects of health, personal and social care. Daily statements and risk assessments identify changing care needs, which were not reflected in the care plans. Initial assessment and care plans for one resident recorded that the resident was fully continent. Daily statements recorded increasing levels of incontinence. Care documentation requires a quality questionnaire to be completed monthly along with a review of care plans. Staff had recorded the response to the quality question in the area for reviewing care plan changes. The current format does not require care plans to be dated it was not possible to identify and track fully these monthly reviews. Staff said that they were learning how to use the new documentation and were finding it easier the more they did. The manager and care manager said that information from each of the residents assessments etc were discussed in unit meetings monthly with staff members and had improved communications with regards to residents care needs. Care files viewed showed involvement of members of the multidisciplinary team in assessing and meeting residents’ care needs. The clinical advisory nurse visited during the inspection. Procedures for the assessment and management of nutritional status require further development. Care records of one resident identified ongoing concern with regards to difficulties with swallowing, there was no record of weights or of any action taken to review the problem identified. Since the last inspection systems for the management and administration of medications has been reviewed and improved, this was undertaken as the result of a reported medications incident. The manager audits the medications regularly. Three of the senior staff said that they had completed medications training. The following issues were identified and discussed: • Directions for the administration of warfarin for one resident were unclear. • Not all prn medications specified the reason for administration. • Eye drops for one resident specified to be given as directed with no further information. • The MAR sheet for one resident’s Trazadone was unclear. Staff were unaware if this had been discontinued or not. The medication was not available but staff had signed for receipt of this medication with the new drug delivery. This was dealt with during the inspection. • Keys to medicines trolleys and cupboards were not held by the senior staff at all times but stored in a drawer. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 10 Throughout the inspection it was observed that staff knock on residents’ doors, offer choices and ensure that all personal care and consultations are conducted in private, this assists in maintaining the residents privacy and dignity. Comment cards returned to the inspector by residents and relatives indicated that the staff treated the residents well and respected their privacy. One resident told the inspector “the staff are very good, they do everything just as we like it.” WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 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) These standards were not assessed as part of this inspection. EVIDENCE: WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 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 standard(s) 16 Systems for the management of complaints are satisfactory residents can be confident that their concerns are listened to, taken seriously and acted up on. EVIDENCE: Relatives visiting at the time told the inspector that concerns raised with the manager had been investigated and action taken as a result of this. Residents told the inspector that if they had any concerns about any aspect of the service they would discuss these with the manager. The complaints procedure is located in reception and is also included in the Service User Guide. The inspector observed the complaints records, which included details of investigations and any action taken as a result. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 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 standard(s) 19 and 26 The standard of décor and furnishings is generally good with evidence of ongoing planned improvement and maintenance. The home presents as comfortable and homely for residents. EVIDENCE: Woodside is registered as a care home providing personal care to 38 older people; this includes a registration for the care of 8 older people with dementia. The dementia unit is situated on the ground floor. Each floor has a lounge and dining area, which have been fitted with kitchenettes. On each floor there is an assisted bathroom, with a shower room provided on both the first and second floors. All bedrooms are single rooms, none have en-suite facilities. A passenger lift to each floor, and ramps leading to outside areas, ensure easy access to all areas of the home.Woodside has a garden area to the rear and a secure garden leading off the dementia care unit. There is limited parking space for staff and visitors to the rear of the home. Furniture and furnishings are homely, the manager told of plans future plans to refurbish the dementia care unit. The carpet area in the lounge diner of the dementia unit requires replacement. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 14 Generally the home was found to be clean and tidy. A number of carpets in resident rooms were observed to be heavily stained the manager said that these are being replaced. There were no obvious odours apart from the corridor area outside room 22 and 23. Bathrooms and shower rooms contained personal toiletries and sponges, non of which were labelled as belonging to individual residents. Three comment cards returned to the inspector identified some difficulties with the laundry services. The manager was aware of these issues and has taken action to address them this includes the provision of additional laundry hours. The manager said she will continue to monitor the service. A tour of the laundry at the time of the inspection found this to be satisfactory. The clinical waste bin was observed to be extremely full and was unlocked throughout the inspection. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 15 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 and 29 After a period of instability in staffing there is now a good complement of staff offering a greater consistency of care within the home. The procedures for the recruitment of staff are satisfactory and protect the residents. EVIDENCE: The inspector observed the duty rotas for the period of a month. These demonstrated that staffing numbers were being maintained within agreed levels. Staff sickness was covered by relief staff and others doing additional hours. The manager told the inspector that senior staff were allocated additional hours supernumerary hours to complete the care documentation and assessments. One comment card returned to the inspector indicated that occasionally at weekends staffing levels were reduced. During the inspection residents said that staff were available to them should they need help. Staff told the inspector that staffing levels had improved and they were able to meet residents’ needs. The inspector examined the records of three recently appointed staff members. Each file contained evidence of suitable CRB checks, references and all other information as required by this standard. A management checklist on the front of each file evidenced that staff had been given copies of the General Social Care Council Code of Conduct. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 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 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) 33 and 38 The quality management systems in this home are developing, with evidence that residents’ views are sought and acted upon. The health and safety of residents and staff are promoted and protected. EVIDENCE: A comprehensive quality management system linked to resident assessment and care planning has recently been implemented. A management matrix is completed monthly, which enables the homes manager and senior managers to monitor aspects of care and staffing throughout the home. This includes dependency levels and staffing, accident/incidents and complaints. Residents are asked one quality question each month and the responses are recorded. (The manager is responsible for answering for those residents in the dementia unit.) Throughout the year this will give an overall indication on residents views of the home. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 17 A resident/relatives meeting was recently held with records of this seen at inspection. In addition to this there is a compliments/complaints book on each floor. Policies are produced corporately a number of these require review. Evidence was seen of regular servicing of major systems. Reports by the Fire Officer, Health and Safety Officer and Environmental Health were observed these were satisfactory. The report of a recent internal health and safety audit is awaited. Records of staff training were observed with good numbers having attended fire, manual handling and first aid. Systems for identifying staff still to attend training are satisfactory. Infection control training is planned for August 2005. Accident records were observed, the quality system enables the manager to monitor accidents/incidents and the accuracy of recording. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 2 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 Standard No 16 17 18 Score 3 x x x x 2 x x x x 3 WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 19 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 OP 7 Regulation 15 Requirement Timescale for action 30/09/05 2. OP 9 3. OP 14 4. OP 26 The registered manager must ensure that assessments and care plans are specific to each residents, health, personal and social care needs and are up to date. 13 The registered manager must ensure that : MAR sheets clearly state the dosage of medication (see main body of report) Medications precribed as prn clearly state the reason for administration. Accurate record are maintained of medications received from pharmacy. A copy of the current FP10 must be obtained for each resident. The systems for the management of the drug cupboard keys is reviewed. 17 The registered manager must Schedule ensure that an inventory of 4 personal items of furniture brought into the home by residents is maintained. (this standard is part met ) 23, 13, 16 The registered manager must ensure that the stained carpets are cleaned/replaced as E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc 31/08/05 81/08/05 30/09/05 WCS - Woodside Version 1.40 Page 20 5. 6. 7. OP 26 OP 26 OP 36 necessary. Unpleasant odours must be dealt with. 13, 16, 23 Personal toiletries must be returned to residents rooms and stored safely. 13, 16 Clinical waste bins must be kept locked. 26 The registered person or a representative of the registered provider must visit the home monthly and produce a written report on the conduct of the home. (Old timescale of 30.04.04 not achieved) 30/08/09 12/07/05 31/08/05 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. 4. Refer to Standard OP 7 OP 7 OP 9 OP 33 Good Practice Recommendations The inspector recommends that the manager reviews the current care documentation for residents who are admitted for short/respite stays. The inspector recommends that care plans are dated and signed by the staff members responsible and whenever there are any changes to these. The inspector recommends that the manager check with the prescribing GP the current medications of short stay/respite residents on admission to the home. The inspector recommends that the manager consider the use of dementia care mapping as a method of monitoring the quality of the care/service in the dementia unit. Consideration should also be given to the method of feedback to residents and relatives of the findings of the monthly quality questions asked of each resident. WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 WCS - Woodside E53 S4271 WCS - Woodside V239170 110705 Stage 4.doc Version 1.40 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. 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