CARE HOMES FOR OLDER PEOPLE
Woodbank Woodbank Hollybank Road Woking Surrey GU22 0JP Lead Inspector
Helen Dickens Announced Inspection 15/9/05 10:00 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 Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Woodbank Address Woodbank Hollybank Road Woking Surrey GU22 0JP 01483 773684 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) Methodist Homes for the Aged To Be Confirmed Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Bedroom 13 (Double) to be used for married couple only. Date of last inspection 25.02.2005 Brief Description of the Service: Woodbank is managed by the Methodist Homes for the Aged and is one of a number of homes administered by the organisation. Woodbank is a large detached property in a quiet residential area of Woking, close to local facilities. The home offers accommodation on two floors, the upper floor is accessible via the stairs and a lift. There are 38 single bedrooms and one double bedroom. Residents have access to a small kitchen on the first floor. The main kitchen and dining room are on the ground floor. There is some staff accommodation, which is situated on the first floor. Visitors’ parking is available at the front of the house and on the road. There is a mature, well-kept garden, which is accessible to wheelchair users. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place over 8 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Melanie Roesch, the recently appointed Manager, represented the establishment. A tour of the premises took place. The pre-inspection questionnaire, a number of comment cards, and other documents relating to the care of residents and procedures in the home were also examined during the inspection. Two members of staff and four residents were interviewed and the inspector greeted most of the other residents during the visit. This was a very positive inspection. The inspector would like to thank the new Manager, residents and staff, for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection?
Since the last inspection a new manager has been recruited and a number of administrative activities have improved. Record keeping, especially care records, have shown particular improvement under the temporary manager who has managed the home until recently.
Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 6 The requirements from the last inspection have been met including updating the Statement of Purpose and Service Users Guide. A repair in one bathroom had been carried out and some outstanding health and safety matters had been attended to. It had been recommended that the home review whether to offer a cooked breakfast to residents and they had carried out a survey of residents to gain their views. Local policies on medication, and dying and death, had also been produced, as recommended by the previous inspector. The home has purchased a large television with the ‘free view’ facility and the living room has, with resident’s permission, been rearranged into smaller circles to enable better conversation between residents. Decoration and refurbishment since the last inspection includes the conservatory and library, and the replacement of downstairs carpets. 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.
Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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 Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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 5. Prospective residents have the information they need to make an informed choice about whether to move into this home. Assessments are sufficient to enable staff to offer the appropriate care to residents. EVIDENCE: The statement of purpose and service user’s guide have been up-dated and contain the information needed to enable prospective residents to make an informed choice about the home. Information on the type of home, services offered and organisational values are set out clearly. Residents are assessed by staff before they come to Woodbank and a care plan is drawn up. Relatives are involved in this where appropriate and trial visits are offered and outlined in the service user guide. The assessment documentation is standard throughout Methodist Homes and offers the opportunity to get a good overview of the residents needs and wishes. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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 and10 There have been improvements in record keeping, especially resident’s care plans, and this enables staff to meet resident’s personal, health and social care needs. EVIDENCE: Care plans are the standard Methodist Homes format and offer a good overview of resident’s needs. Some plans still needed further work to complete all sections but the home has progressed well in this area. There is a key worker system in operation and resident’s needs were well understood by those staff interviewed. One resident commented positively on the local doctors; ‘…you’ve only got to have a bit of trouble and the doctors come out’. He was very pleased that ‘medically there is always someone here’. Another resident said she had angina but had been looked after very well. Care plans documented healthcare needs and there were good written records of visits and interventions by community healthcare staff. There was one complaint about healthcare and this is covered in the section of this report
Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 10 dealing with complaints. Continence supplies have been made available for residents from the community nurses. However, there was no evidence of continence assessments on those resident’s files examined. It was recommended that such assessments be clearly recorded. The administration of medicines was not inspected on this visit but the inspector noted a good report had been received from the visiting community pharmacist. However, on the day of the inspection a member of staff was seen to leave tablets on the table for a resident to take later. The manager was asked to review this practice. She was also reminded that any errors in the administration of medication should be reported to CSCI on a Regulation 37 notice. The home must review whether it needs to apply to CSCI for a variation to its category of registration. The needs of some residents appear to have changed since admission and the home must ensure that Woodbank is operating correctly in this respect. Residents were observed to be treated with dignity and respect by staff and those residents interviewed made positive comments about their relationships with staff. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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): 12,13 and 15 Woodbank works hard to engage residents in enjoyable social, cultural and recreational pursuits. Contact with family, friends and the local community is encouraged. Residents generally receive a wholesome and appealing diet in pleasant surroundings. EVIDENCE: Woodbank has its own activities organiser working 25 hours per week over four days. In addition, volunteers assist with an art group. There was much evidence of art and craftwork, and residents had been working on the harvest festival theme, producing an attractive collage. Quizzes and ball games are also part of the activities timetable. One member of staff could play the piano well and did a session each time he was working which was usually 5 days per week. A visiting library comes to Woodbank on a regular basis. One resident also told the inspector he felt it was a nice touch that there was always a newspaper in the lounge for residents – he felt it helped people keep in touch with the outside world. Resident’s wishes are taken into account in planning activities and events both at the resident’s meetings and through ad hoc surveys. The activities plan is on the central notice board but residents have also requested an individual copy and this has been put in place.
Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 12 Being a Methodist Home, spirituality is given particular attention and details of arrangements are in the service user’s guide to the home. Family and friends are welcome to visit and this is also set out in the service users guide. Some very positive comments were received from visitors, one writing in the comment card that ‘staff provide and extend a caring and accepting ethos to all residents and visitors’. Another visitor who helps out in the garden on a voluntary basis said the new manager always makes a point of thanking him for his help. On the day of the inspection the inspector joined residents for lunch. The meal was pleasant and consisted of savoury minced beef, boiled parsley potatoes and vegetables. There was more than enough food and residents could help themselves to the potatoes and other vegetables. The dining room was nicely set out with linen cloths and napkins. Some residents who needed help were being given sensitive assistance. The menus were varied and residents had a choice of meal. Generally the comments on the food were favourable but several mentioned ‘tough meat’ and the complaints and suggestions book had a few negative comments relating to the food. The manager was currently getting quotes to change the butcher and try to address this ongoing problem. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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 complaints and protection systems within the home need to be strengthened in order to better protect residents. EVIDENCE: A number of complaints have been received since the last inspection. Some complaints written in the ‘comments and suggestions’ book were fairly minor and mainly concerned the food. It was not clear on every occasion how these issues had been addressed. The book was an excellent idea, kept in an accessible place, and residents were encouraged to use it. A visitor said that he had put in a complaint that there should be two staff upstairs to assist residents to go down in the lift (or on the stairs) at busy periods such as lunchtime. He did not know what the outcome had been and this had happened during the management of Woodbank by the temporary manager. The inspector brought this to the attention of the new manager. A more serious complaint was received and copied to CSCI by a relative. The home was asked to investigate and respond directly to the complainant. The issues concerned the lack of a permanent manager and concerns about the falling standards within the home. This was dealt with according to the home’s complaints procedure and a full response was given and copied to CSCI. The day before the inspection a further complaint about Woodbank was sent to the head office of Methodist Homes, it was also copied to CSCI. At the time of
Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 14 writing, this matter is still being dealt with and details will be contained within the next report. In addition, on the morning of the inspection, a relative telephoned through to the office of CSCI and highlighted a number of issues. The inspector looked into these matters during the inspection and responded directly to this relative. The manager was asked to collate a central record of complaints within the home and make this available at future inspections. Details of any complaint, the complainant, investigations carried out and the outcome, should be carefully documented. This will also assist the home to monitor and address any trends in complaints and ensure a consistent approach. On the day of the inspection the Surrey multi-agency procedures for the protection of vulnerable adults was not available in the home. The home was asked to acquire the February 2005 version of this document and staff need to be familiar with its contents. The homes own policy needed to be up-dated and contain clear guidance about the role of social services. The manager was reminded that any ‘complaints’ containing issues relating to possible adult protection issues must be notified to social services immediately. There did not appear to be a record of when staff had last received training in the protection of vulnerable adults and this needs to be clarified. All staff have been booked on this training for next year but some interim training may be necessary. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 15 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 Residents live in a safe, well-maintained environment though there are a few planned refurbishments outstanding, which are currently detracting from the otherwise pleasant ambience. EVIDENCE: The location and layout of the home is suitable for its stated purpose and has generally been furnished and decorated in a homely way. Some recent refurbishments have greatly improved the comfort of residents, in particular the sun lounge and library area. The requirements made at the last inspection relating to this standard have been met and there is an ongoing programme of refurbishment and redecoration. The upstairs carpet needs replacing and a door needs repainting; requirements will be made in this regard. On the day of the inspection the home was clean and hygienic and there were no unpleasant odours. Indeed several of the bathroom and toilet areas were particularly fragrant. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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): 28 The home needs to review the number of staff with NVQ training in order to ensure that residents are in safe hands at all times. EVIDENCE: The record keeping on staff training has improved since the last inspection and a large chart with all staff names and training attended has been created and is displayed in the office. The manager said that of the 22 care staff, 8 have completed NVQ levels 2 or 3. In addition, 9 others have started NVQ courses, though some only started in June 2005 and are therefore unlikely to finish by December 2005. The manager also said that they use bank staff, none of whom have NVQs. The manager must review this in order to ensure that 50 of the home’s staff are trained to NVQ 2 or above by December 2005. The manager must also review the issue regarding training in the protection of vulnerable adults as set out earlier in this report. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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): 31,32,33,36,37 and 38 After a period of temporary management, the home is now in a position to move forward to ensure that residents live in a home which is well run, and where their views are properly taken into account. EVIDENCE: The new manager has experience of being in a senior position in a care home and has two management qualifications. She is currently studying for the Registered Managers Award. She must complete her application to become registered with CSCI as soon as possible. The manager demonstrated a clear commitment to improving the well being of residents and to building on the administrative improvements begun by the temporary manager. There was an open and positive atmosphere within the home throughout the inspection.
Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 18 There were a number of ways of measuring the quality of service to residents including the Regulation26 visits to the home and resident’s meetings. There was also the ‘suggestions and comments’ book in the hallway and surveys of resident’s opinions on particular matters. However, the annual quality assurance exercise was behind schedule and would not be starting until November. A requirement will be made regarding the importance of this exercise being carried out in a timely fashion. The manager said supervision with staff was both formal and documented and the inspector noted that procedures were in place to give extra support and supervision when circumstances required it. However, there needs to be six, rather than only four documented sessions of supervision for care staff each year. Record keeping at the home continues to improve, especially resident’s care plans and risk assessments. There were a number of gaps, which still needed to be completed, and this is an ongoing project for the manager and senior staff. The health and safety of residents and staff was taken seriously at Woodbank through staff training and supervision. The inspector checked tap water temperatures at a variety of outlets within the home and all were found to be within safe limits. However, on the day of the inspection the hazardous substances cupboard was not securely locked and an Immediate Requirement was made in this respect. The inspector noted that the fire brigade were due to visit within the next two weeks, but no record of the last visit from the Environmental Health Department could be found. The inspector discovered that some incidents affecting the welfare of residents, e.g. falls, had not been reported to CSCI and guidance was given in this regard. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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 3 X 3 X 3 N/A 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 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X X 2 2 2 Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 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 OP7 Regulation 15(1) Requirement The work on improving care plans and other documentation relating to residents well being must continue until all documents are complete and up to date. The home must review its practice of leaving medication on the table for residents to take later. All medication errors must be reported to CSCI under Regulation 37 notices. The home must review how complaints are documented and monitored in line with the suggestions in this report. The home must review staff training with regard to the protection of vulnerable adults as detailed in the report. Outstanding maintenance and decorative issues including replacement of the upstairs carpet and painting the bedroom door must be dealt with in order to fully meet this standard. The home must review its staff training in order to meet the standard and have 50 of all
DS0000013836.V249877.R01.S.doc Timescale for action 15/11/05 2 OP9 13(2) 22/09/05 3 OP16 17(2) 22(3)(4) (8) 13(6) 15/10/05 4 OP18 15/10/05 5 23(2)(d) 15/11/05 6 18(1)(a) 15/12/05 Woodbank Version 5.0 Page 21 7 8 9 10 11 8(1) CSA Section 11 24(1) The manager must ensure that the annual quality assurance process commences as planned as it is already behind schedule. 18(2)(a) Supervision of care staff should be formal and documented and occur at least 6 times per year. 17(1)(2) Records required by regulation must be available within the home and be kept up to date. 13(4)(a) The hazardous substances (c) cupboard should be secure at all times . The last Environmental Health Officer visit record must be found, or a further visit requested. All incidents adversely affecting the welfare of residents must be reported to CSCI under a Regulation 37 notice. care staff with NVQ2 or above by December 2005. Agency and bank staff must be included in this ratio. The manager must complete her registration with CSCI. 15/11/05 15/11/05 15/12/05 15/11/05 15/09/05 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 Refer to Standard Good Practice Recommendations Continence supplies should only be provided following a proper assessment, details of which should be recorded on each resident’s plan. Woodbank DS0000013836.V249877.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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