Inspection on 09/01/06 for Woodbank

This inspection was carried out on 9th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Woodbank 05/12/06

Woodbank 15/09/05

Woodbank 25/02/05

Woodbank 28/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Woodbank Woodbank Hollybank Road Woking Surrey GU22 0JP Lead Inspector Cathy Clarke Unannounced Inspection 9th January 2006 09:30 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 Woodbank DS0000013836.V278710.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. Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 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) home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Melanie Roesch Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bedroom 13 (Double) to be used for married couple only. Date of last inspection 15th September 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.V278710.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of 4 hrs and was the second inspection to be undertaken in the Commission for Social Care Inspection Year April 2005 to March 2006. Lead Inspector Cathy Clarke was assisted throughout the inspection by Laura Minns and Michelle Nelson representing the establishment. Service users prefer to be known as residents and will be referred to as such throughout this report. A tour of the premises took place and documents inspected included, care plans, staff recruitment and training records, policies and procedures. Five residents were spoken to during the inspection. The inspector would like to extend her thanks to the residents, and staff at Woodbank for their assistance and hospitality. What the service does well: What has improved since the last inspection? What they could do better: The organisational structure held within the statement of purpose had not been completed fully and it is recommended that this be done. Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 6 The home must display the current insurance certificate in a prominent place. Safeguarding Adults training must be provided for all staff and staff must be made aware of the policies and procedures for the protection of vulnerable adults. Recruitment records must be checked for accuracy and where gaps in employment are indicated the reasons for the gaps must be explored and recorded. All information and documents listed in schedule 2 of the Care Homes Regulations must be in place prior to the commencement of employment. 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.V278710.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 Woodbank DS0000013836.V278710.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): 1,6 Comprehensive information regarding the home is available for prospective residents and planned assessments are undertaken prior to moving into the home. EVIDENCE: There is a comprehensive statement of purpose. The organisational structure held within the statement of purpose had not been completed fully and it is recommended that this be done. The current certificate of insurance must be displayed in a prominent place. The home does not offer intermediate care but does provide respite care for a period of up to three weeks. One of the residents spoken to during the inspection stated that she had moved into the home recently to be nearer to family and was settling in well. Woodbank DS0000013836.V278710.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): These standards were not assessed during this inspection. EVIDENCE: Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 10 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 Residents take part in various activities in the home and in the local community. Regular meetings are held with residents to assist them with making choices. EVIDENCE: The member of staff responsible for activities was providing an activity programme for residents in the lounge. Five of the residents were sitting in the conservatory in the morning and enjoy looking out over the garden. An extra fan heater had been put in the conservatory to provide a warm environment for residents. Regular staff and residents meetings are held and the views of residents are listened to and acted upon. A local theatrical group is to perform a pantomime within the home using money from the amenities fund to finance the project. Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 11 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): 16,18 Policies are in place to protect residents from abuse and neglect and a complaints process is in place. A more formal method must be adopted for recording complaints. EVIDENCE: There is a complaints book in the office for residents to make comments regarding any issues. A book should be held separately for formal complaints, as the current book has become more of a communication book. One complaint was received by Methodist Homes and a copy was forwarded to CSCI, this was fully investigated by the provider using its complaints procedure and the outcome was sent to CSCI and the complainant. Staff spoken to during the inspection were unaware of the vulnerable adults policies and procedures and confirmed that they had not received training. Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 12 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): 20 The internal and external communal areas are safe and accessible to residents, staff and visitors. EVIDENCE: There is a large communal garden to the rear of the property, which is maintained by a member of staff and one of the resident’s sons who likes to volunteer his help and assistance. There are various sitting rooms and a conservatory where residents can sit and entertain their guests. Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 13 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): 27,29,30 The number and skill mix of the staff group meets the needs of the service users living within the home. Recruitment practices need to be improved to ensure that reasons for any gaps in employment details are explored and recorded. EVIDENCE: Four staff were on duty according to the staff rota in the morning with a further four in the afternoon plus a senior carer. An experienced staff member is shadowing one member of staff until all necessary recruitment checks have been received by the service. A weekend domestic carer has been recruited to the team making a total of three domestic staff within the home. There is one laundry assistant who was ironing and washing residents clothes during the inspection. One part-time cook has been recruited and will commence with the home as soon as they receive a satisfactory outcome from recruitment checks. There are also two assistant managers. Two sets of recruitment records were sampled during the inspection. One of the application forms simply had the number of years that the employee had worked for other employers without the dates. No records were found of explanations for gaps in employment. The staff induction programme sampled was comprehensive; staff were unaware of the foundation training programme. Two members of staff spoken Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 14 to during the inspection confirmed that they had not received Protection of Vulnerable Adult training. There is a staff-training plan for the year and staff have received fire safety and dementia care training. Basic food hygiene, first aid and medication training has been booked for all new staff. Four staff have completed NVQ Level 2, two staff have completed NVQ Level 3 and nine other staff have been registered and have commenced a programme of training towards these awards. Please see requirements and recommendations section of this report. Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 15 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 There are policies and procedures in place for the safekeeping and administration of resident’s finances. EVIDENCE: According to staff approximately 40 of residents deal with their personal finances. Some residents have power of attorney arrangements in place. Written records are held on resident’s money and financial transactions. Money is stored in a safe place. Each resident has a wallet with his or her money in. The head office of Methodist Homes conducted an audit inspection of all finances in December 2005. During the inspection the treasurer of the Amenities fund visited the home to deposit some money into the fund. The treasurer them takes the financial transaction book to check the funds expenditure. Once the records are signed off as correct the book is returned to the home. Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X 3 X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? YES 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 2 Standard OP1 OP16 Regulation 25 (2) (e) 17 (2) 22 (3) (4) Requirement Timescale for action 31/01/06 3 OP18 13 (6) The current insurance certificate for the home must be displayed in a prominent position. The home must review how 31/03/06 complaints are documented and monitored. This was a requirement from the previous report a revised timescale has been given. Safeguarding Adults training 31/03/06 must be provided for all staff and staff must be made aware of the policies and procedures for the protection of vulnerable adults. This was a requirement from the previous report and a revised timescale has been given. Recruitment records must be checked for accuracy and where gaps in employment are indicated the reasons for the gaps must be explored and recorded. All information and documents listed in schedule 2 of the Care Homes Regulations must be in DS0000013836.V278710.R01.S.doc 4 OP29 19(4)(b) (6) Schedule 2 31/01/06 5 OP29 19(4)(b) 19 Sched 31/01/06 Woodbank Version 5.1 Page 18 2 place prior to the commencement of employment. 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 OP1 Good Practice Recommendations It is recommended that the management structural map in the statement of purpose be fully completed with the relevant staff names. Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 19 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 © 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 Woodbank DS0000013836.V278710.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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