Inspection on 21/02/06 for Woodbank House

This inspection was carried out on 21st February 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 House 11/01/07

Woodbank House 02/08/05

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 Mrs Debbie Foster Unannounced Inspection 21st February 2006 8:30am 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 DS0000003031.V278709.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. DS0000003031.V278709.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodbank House Address 317 Chesterfield Road Sheffield South Yorkshire S8 0RT 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) 0114 255 1822 0114 250 7004 Mrs Jacqueline Margaret Byron Mrs Jacqueline Margaret Byron Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places DS0000003031.V278709.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 2nd August 2005 Date of last inspection 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. DS0000003031.V278709.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day. The manager, assistant manager, 4 staff and 8 service users spoke with the inspector during this time. Aspects of certain records were checked. Interaction between the staff and the service users were observed. Aspects of the environment were inspected. The inspection started at 8:30 am until 3:35 pm. Feedback on the inspection was given to the manager. What the service does well: What has improved since the last inspection? The manager said they had continued to work on formalising practices and improving on the homes recording systems. The refurbishment and decorating programme had continued within the home. A number of areas had been fitted with new carpets. The majority of the previous requirements made in the last inspection report had been progressed. DS0000003031.V278709.R01.S.doc Version 5.1 Page 6 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. DS0000003031.V278709.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 DS0000003031.V278709.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): Standards 3 and 5 were checked on the last inspection. The home does not offer intermediate care. EVIDENCE: DS0000003031.V278709.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): 7, 8, 9 and 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. 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. Risk assessments had been undertaken covering safety risks to the service users and information and action to be taken by the staff on how to reduce or eliminate the risk identified. Since the last inspection the detail recorded in the care plans had improved. In the main specific details were recorded for staff to follow. However, there were still areas for further development. There were still some areas not detailing specifically clear DS0000003031.V278709.R01.S.doc Version 5.1 Page 10 instructions of the care for staff to follow (eg on oral hygiene/aspects of personal care). Service users 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 were “helpful”, “polite” and “caring”. One service user said, “nothing was too much trouble”. The requirements made on the last inspection were checked for standard 8. The service user records checked recorded the health care needs and professionals visiting the service users. Again on occasions some specific detail was lacking. The daily recordings had improved since the last inspection. However, they did not always detail all the care given to reflect the service user individual plan. Aspects of this standard were checked. The administration of medication was observed and the corresponding records were checked. A member of staff was observed not dispensing medication to a service user in line with good hygiene practices or offering the service user a drink to aid swallowing tablets. The assistant manager was informed of this. The medication administration record sheets information checked corresponded with the mediation dispensing cassettes or boxes. The staff were able to explain how they would respect the service users privacy and this was confirmed by service users. 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. Staff were seen speaking to service users appropriately. DS0000003031.V278709.R01.S.doc Version 5.1 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, 14 and 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. Choice and control over their lives was promoted for the service users at the home to give them autonomy. The menu at the home offered choices, including healthy options to promote a healthy eating and a balanced diet for the service users. 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. Others said they joined in the board games and bingo. The majority of service users were alert and interacting with one another or staff during the inspection. A singer visited the home on the day of the inspection. Service users were seen singing along and looked to be really DS0000003031.V278709.R01.S.doc Version 5.1 Page 12 enjoying the entertainment. Some service users visited the local shops with staff. Staff said they had regular entertainment at the home. Relatives visiting were seen being made welcome and were offered a drink. 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 their family and friends could visit the home at any time. Service users were seen making choices about their daily lives in a number of ways during the inspection. These were, activities, meals, rising and retiring times. Staff said they were asked what they would like to wear on a daily basis. Service users said they could go to their bedrooms when they so wished and gave accounts of how staff consulted them about their preferences. The bedrooms seen were personalised. Service user meetings were held at regular intervals. Service users said the quality of food served was good and that “there was always a choice”. One service user said the food as “marvellous”. 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. There was a hot and cold option at the teatime meal. The cook was seen going around individually to each service user to take their order for the following meal. Some service users took breakfast in their rooms. Staff were seen assisting service users to eat in an appropriate manner. There was fruit accessible to service users in the lounge. There were details in the kitchen of the service users on special diets. DS0000003031.V278709.R01.S.doc Version 5.1 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 Service users said that complaints would be acted upon ensuring they were listened to. However, the policy and recordings had omissions. In the main service users were protected from abuse by the awareness of staff through training and the homes procedures. EVIDENCE: Staff and service user said they knew how to complain. A complaints procedure was displayed in the home. The homes policy for complaints did not detail the timescale in which a complaint would be investigated and the complainant receives a conclusion. Service users said that if they had any concerns that they would feel comfortable in talking matron or the manager and they felt their issues would be addressed. There had been no formal complaints made since the time of the last inspection. The home did have a recording system for complaints. However, they did not always record the outcome of the complaint and if the complainant was satisfied with the outcome. The staff interviewed said they had received adult protection training or were booked to attend in the next few months and the records checked confirmed this. The home had a adult protection policy and procedure and the Department of Health Guidance No Secrets. The home had made no referrals to the protection of vulnerable adults register since the last inspection. DS0000003031.V278709.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21, 23, 24 and 26 Comfortable indoor and outdoor communal facilities were provided to give service users a pleasant environment to live in. Toilets and bathrooms for the service users were in sufficient numbers to ensure adequate facilities for the service users who were resident in the home. However, water temperatures at sink outlets were high which could be a health and safety risk to service users. Service users had safe, comfortable bedrooms with their own possessions around them. The home was clean to ensure a pleasant environment for the service users to live in. Training on infection control was being given to all staff. DS0000003031.V278709.R01.S.doc Version 5.1 Page 15 EVIDENCE: 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. Since the last inspection a number of new carpets in communal areas had been replaced the dining room. The lounge had been decorated and a number of bedrooms. Service users commented that they thought that they had a comfortable environment to live which was always clean, warm and tidy. 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. Water temperatures at sink outlets were high which could be a health and safety issue to service users this was also identified on the last inspection. Subsequent to the inspection the manager informed the Commission for Social Care Inspection that the water temperatures in the home had been checked and adjusted. Nurse call cords were accessible for service users when using the toilet. 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. The manager said a number of chairs had been replaced in bedrooms. 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 staff said they 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. DS0000003031.V278709.R01.S.doc Version 5.1 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): 27, 28 and 30 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. Staff were not fully trained to do their job to ensure they could meet all the needs of service users. 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. In the main the home had four staff on duty in the morning and three on duty on the afternoon shift. Service users said staff responded to their requests for help within reasonable time scales and when giving assistance this was undertaken unrushed. The home had sufficient ancillary staff to keep the home clean. Staff said they did have training opportunities and care workers were undertaking NVQ training. The home had not yet achieved the target set of 50 for its work force to achieve this qualification but they were on track to have over 50 of the work force undertaking the qualification by January 2007. The manager said that the home had been actively training the work DS0000003031.V278709.R01.S.doc Version 5.1 Page 17 force and had NVQ assessors to assist meeting the NVQ targets. The staff interviewed said they undertaken the majority of mandatory training (eg food hygiene, health and safety, moving and handling, personal care). Some staff, were to undertake infection control and adult protection training, this training was planned. DS0000003031.V278709.R01.S.doc Version 5.1 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 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): 33, 35 and 36 Effective quality assurance systems were not fully in place to pick up on omissions and mistakes. Although a number of areas were audited to ensure the home is running in the best interest of the service users. In the main the home had systems in place to safeguard the financial interests of the service users they were supporting by recording transactions and holding receipts. Staff were being formally supervised to ensure fully individual staff development and the monitoring of care practices. EVIDENCE: The manager said that quality assurance systems were being developed further to monitor the service and care provided in the home. The quality DS0000003031.V278709.R01.S.doc Version 5.1 Page 19 assurance system did not record areas picked up on for improvement. Since the last inspection questionnaires had been sent out to relatives to gain their views on the service. However, the results of the survey on the service had not been collated to indicate what they were doing well and the areas for improvement and the action to be taken. Regular residents meeting took place, which included getting their views on aspects of the service. Some omissions were found in case files, with some practices and records. The manager said that the home handled a number service users personal allowances. Two records were checked, there were income and expenditure recorded and receipts were kept. However, some receipts were held centrally rather than individual (holding third party information). The accounts were not audited the manager said. Service users said they had access to their money when they wanted it and could spend it on what they liked. Some service users were supported to manage their money to help make it last. The weekly spending allowance for service users after paying for their care is not a substantial amount and if someone smokes it does not go for. The manager and staff said that formal supervision was taking place to ensure the standard of care practices were being monitored. The records seen confirmed this. DS0000003031.V278709.R01.S.doc Version 5.1 Page 20 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 X X X X X 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X 3 2 X 3 3 X 2 STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 3 X X DS0000003031.V278709.R01.S.doc Version 5.1 Page 21 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 OP8 CH7 Regulation 15 Requirement Further information on actions needed and taken by staff to meet service users needs must be included on all plans of care. This requirement has been outstanding since March 2005. All staff must administer medication in line with good hygiene practices and a drink must always be offered to assist in taking medication. The outcome of complaints must be recorded and details of whether the complainant is satisfied with the outcome of the complaints. 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 tempreture. This requirement has been outstanding since August 2005. This was discussed with the manager at the time of the inspection to ensure immediate DS0000003031.V278709.R01.S.doc Timescale for action 28/05/06 2 OP9 13 28/03/06 3 OP16 22 28/04/06 4. OP21 23 22/02/06 Version 5.1 Page 22 5 OP18 OP30 OP26 13 & 16 6 OP33 24 7 OP35 12 & 25 action was taken. All staff must receive training on infection control. This requirement has been outstanding since March 2005. All staff must receive training in adult protection. The quality assurance system must be developed further. Relatives views on the service must be collated collectively and any points to improve the servcie acted upon. The monitiring recording system must record ommissions and deficiencies and the action taken to rectify. Individual receipts must be obtained for all financial transactions made on behalf of servcie users. Service users accounts must be audited. 28/05/06 28/06/06 28/06/06 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 OP28 OP12 Good Practice Recommendations The home must have a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent). The good selection of activies and entertainment should be built on further to continue the positive selection of ‘things to do’ with in the home. DS0000003031.V278709.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Sheffield Area Office 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. 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