Inspection on 02/08/05 for Woodbank House

This inspection was carried out on 2nd August 2005.

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 House 11/01/07

Woodbank House 21/02/06

Woodbank House 09/03/05

Woodbank House 31/08/04

Woodbank House 24/02/04

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

CARE HOMES FOR OLDER PEOPLE Woodbank House 317 Chesterfield Road Sheffield South Yorkshire S8 0RT Lead Inspector Debbie Foster Unannounced 2 August 2005 07:20am -15:25pm nd 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. Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodbank House Address 317 Chesterfield Road Sheffield South Yorkshire S8 0RT 0114 2551822 0114 2507004 None Mrs Jacqueline Margaret Byron 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) Mrs Jacqueline Margaret Byron PC - Care Home Only 26 Category(ies) of OP Old Age (26) registration, with number of places Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: One service user, named on the variation application form dated 5.11.03 and who is under the age of 65, may live at the home. Date of last inspection 9th March 2005 Brief Description of the Service: Woodbank House is registered to provide residential care for twenty six older people. It is privately owned. The home is situated in a residential area of Sheffield with easy access to public transport, shopping centres, pubs, post office and clubs. The home is a two storey older property. Access is provided by a lift to upstairs rooms. There are fourteen single bedrooms and six double rooms. There is a large well-kept garden to the rear of the property and a car park. Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day. The registered/owner manager, 7 staff, 3 relatives and 10 service users spoke with the inspector during this time. Aspects of certain records were checked. Interaction between the staff and the service users was observed. Aspects of the environment were inspected. The inspection started at 7:20 a.m. until 15:35 p.m. Feedback on the inspection was given to the registered/owner manager. What the service does well: What has improved since the last inspection? What they could do better: The home should continue to build on developing further its care plans and recordings of the care given to the service users to ensure the regulations and standards are met in full. Woodbank House J55 S3031 Woodbank V241285 020805 UI 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. Woodbank House J55 S3031 Woodbank V241285 020805 UI 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 Woodbank House J55 S3031 Woodbank V241285 020805 UI 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 & 5 No service user moves into the home without having his or her needs assessed to be assured that these will be met. Prospective service users and their relatives have the opportunity to visit and assess the quality, facilities and the suitability of the home to assist them making a decision about whether they wish to live at the home or not. EVIDENCE: Aspects of three service user files were checked. Each file had a social services full needs assessment summary. The manager assesses all service users needs prior to admission. This included a section on health needs of the service user. This was to ensure that their needs can be met once moving into the home, the records checked confirmed this. Relatives informed the inspector that they had visited the home to check out the facilities on offer prior to service users making decisions to come and live there. Woodbank House J55 S3031 Woodbank V241285 020805 UI 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, 9 & 10 In the main the service users health, personal and social care needs were set out in individual plans of care to ensure service users receive the care they need. In the main the administration, recording and storage arrangements for Medication were satisfactory to meet the needs of service users. Service users were treated with respect and their right to privacy was upheld. Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 10 EVIDENCE: Aspects of the service user plans were checked in relation to requirements made on the last inspection. The care plans had been reviewed on a monthly basis. The service user plans included details of the wishes of service users regarding funeral arrangements. Risk assessments had been undertaken covering safety risks to the service users and information and action needed to be taken by the staff on how to reduce or eliminate the risk identified. However, a care plan had not yet been compiled for a new service user in a paper record although there was some information in the assessments undertaken prior to admission on the care they required. The manager said there was a care plan on the computer but only the person in charge of the shift had access to this. There were still areas for further development in the care plans, as specific details were not always recorded to give the care staff clear instructions of the care to be given in all areas. Service users and a relative said that the staff attended to their personal care needs and medical assistance provided when needed. Service users said that they were happy in the home and said, “staff are very caring” and ”I’m happy here”. Relative said “the staff are very caring and the residents looked after very well”, “ staff attitude very positive and professional”, “ There is always activities taking place to stimulate the residents” and “we are very happy with the care delivered by staff”. The service user plans checked recorded the majority of health care needs and professionals visiting the service users. However, omissions were found. Some dental check ups were not recorded as taking place. The daily recordings did not always detail all the care given to reflect the service user individual plan. The administration of medication was observed for three service users and the corresponding records were checked. In the main medication administration record sheets information corresponded with the mediation dispensing cassettes or boxes. However one Inhaler medication administration instructions did not correspond with those instructions on the record sheet. Controlled medication was stored and recorded satisfactory. The staff were able to explain how they would respect the service users privacy and service users confirmed this. They were seen knocking on bedrooms doors and waiting before entering. The service users said that the staff were polite and helpful when attending to their personal care and these duties were carried out in private. A service user did mention to the inspector about a recent incident in which he/she considered a staff member not to have spoken Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 11 to him/her with respect. On checking this out the manager had investigated this and had taken appropriate action taken straight away. Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 12 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, 13 & 15. Service users said they made choices about their daily routines and social activities within the home, which enabled them to make their own lifestyle choices. Service users maintained contact with family and friends to enable them to continue community links. The menu at the home offered choices, including healthy options to promote a healthy eating and a balanced diet for the service users. Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 13 EVIDENCE: Service Users said that they could decide which activities they took part in. Several said they enjoyed the regular social events. There was a regular trip to the local trades and labour club. They commented on enjoying recent trips to Chatsworth and Cleethorpes. Others said they joined in the board games and bingo. Two relatives commented that whenever they visited the home there were always activity taking place and this kept the service users stimulated. Service users were seen to being given choices of meal options and where to take their meal. Some service users were observed having a lie in giving them choices in their daily routine. Relatives and service users said visiting times were flexible. They were made welcome and always offered a drink. Two service users had booked an annual holiday. Newspapers were delivered to the home to enable the service users to keep in touch with what was going on in the wider community. Service users said the quality of food served was good and that “there was always a choice”. Menus offered a choice of food at each mealtime. Service users said that they enjoyed their lunch. Drinks were taken around the home in between meals. The meal times observed were unhurried and a relaxed atmosphere was noted. One service user said they thought that sandwiches were on the menu a lot at teatime. This was an option most days but there was always an alternative usually a hot snack. Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 14 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) None The key standards will be checked on the next inspection. EVIDENCE: Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 24 & 26 Service users live in a well-maintained environment to ensure their safety and comfort. The home provided comfortable indoor and outdoor communal facilities. There were sufficient toilets and bathrooms for the service users. The nurse call cord was not accessible to service users in some toilets to ensure there safety. Service users had safe, comfortable bedrooms with their own possessions around them. Staff were aware of hygiene procedures. Training on infection control was being given to all staff. The home was clean to ensure a pleasant environment for the service users. Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 16 EVIDENCE: A maintenance worker is employed. A number of bedrooms had recently been decorated. The grounds were tidy and attractive. The manager said a number of carpets had recently been replaced. The manager said there were also plans to have en suite facilities made in two bedrooms. The communal dining room and lounges were decorated and furnished to a satisfactory standard. There were an array of ornaments and pictures to give a homely impression. The dining room carpet was stained in the entrance. The manager said the home had already identified this and were organising quotes to replace it. One relative thought that the decoration in one lounge was particularly dark which in her opinion made the room gloomy for service users to sit in. Bathrooms were in working order. Service users said they had regular baths and the records confirmed this. Specialist baths/showers were in place to meet the needs of the service users. Some nurse call cords were not accessible for service users when using the toilet. The manager was informed of this during the inspection. The water in one bathroom area was noted to be hot. One toilet door would not close on its rebate. Service user bedrooms checked were personalised, clean and tidy. In the main the required furniture was provided. Lockable facilities to store private items were in place. Some service users had keys to their bedrooms whilst other told the inspector they did not want a key. One chair seat was noted to be stained and gave a poor impression. On the day of the inspection the home was fresh smelling, clean and tidy. Staff explained the procedures they followed to ensure hygienic practices and managing the control of infection. Some had received formal training in this area others were booked to undertake this training. Service users and the staff said that clothing and linen came back from the laundry clean and in good condition. Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 17 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 & 29. The staffing levels were sufficient to meet the full needs of the service users. The home was pursuing NVQ training for staff without the qualification to ensure they would be fully competent in their work and could provide appropriate care to the service users. The recruitment information obtained for staff was sufficient and met the required standard to adequately protect the welfare of residents who lived at the home. EVIDENCE: The staffing levels met the minimum staffing agreement set with the Commission for Social Care inspection from the staff on duty on the day of the unannounced inspection and the rotas checked. Staff said they felt that the staffing levels were sufficient. Staff were seen sat chatting and undertaking social activities with service users at different times of the day. Staff said they did have training opportunities and care workers were undertaking NVQ training. This was confirmed in the records checked. Staff said they had received an induction and additional training had been given on Abuse of Older People. The home had exceeded the target set of 50 for its work force to be qualified at NVQ level 2 or equivalent the manager said. The requirement on the recruitment of staff made on the last inspection was checked. The staff files checked contained Criminal Record Bureau (CRB). Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 18 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) 38 Of the areas checked health, safety and welfare of service users and staff were promoted and protection was in place to ensure service users safety in this area at all times. EVIDENCE: Aspects of Health and Safety were checked. The staff interviewed and the records checked confirmed that they had received fire instruction training in the last six months. Appropriate checks and fire drills had been carried out and recorded. The staff interviewed the records checked indicated they had received first aid training. Equipment around the home had been serviced within the last twelve months. The new staff interviewed said they had received induction training, which met the TOPPS standard, which includes safe working practices. Woodbank House J55 S3031 Woodbank V241285 020805 UI 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 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 2 2 x 2 2 x 2 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 x x x x x x x x x x 3 Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 20 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. Standard OP7 Regulation 15 Requirement Further information on actions taken by staff to meet service users needs must be included on all plans of care. This requirement has been outstanding since March 2005. Care plans must be compiled and accessible to all care staff at the point of admission for a service user. All health care check ups must take place and be recorded. Medication instruction must be specific on the medication administration record sheet and correspond with the prescription label on the medication. The dining room carpet must be clean to remove the stained area or be replaced. Nurse call cords must be accessible to service users when using the tiolets in the home at all times. The temperature of the water at outlets used by service users must be checked immediatley and appropriate action taken if necessary to ensure the water is set at the stipulated temperature. Timescale for action 28.10.05 2. 3. OP7 & OP8 OP9 12 & 13 13 28.10 .05 28.08.05 4. 5. OP20 OP21 23 23 28.01.06 3.08.05 Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 21 6. 7. OP23 OP26 23 13 & 16 The bedroom chair in room 22 must be cleaned to remove the stain. All staff must receive training on infection control. 28.09.05 28.10.05 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. Refer to Standard OP15 OP20 Good Practice Recommendations The home should review the tea time menu with service users to ensure it meets with there requirements and needs. Consideration to the colour of the decoration in the non smoking lounge should be reviewed and made brighter if the service users so wish. Woodbank House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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 House J55 S3031 Woodbank V241285 020805 UI Stage 4.doc Version 1.40 Page 23 - 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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