Inspection on 22/06/06 for Woodberry Grove

This inspection was carried out on 22nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodberry Grove 30/11/06

Woodberry Grove 25/10/05

Woodberry Grove 11/04/05

Woodberry Grove 01/09/04

Woodberry Grove 01/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Woodberry Grove 91 Wellington Road Bush Hill Park Enfield Middlesex EN1 2PW Lead Inspector Margaret Flaws Key Unannounced Inspection 22nd June 2006 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 Woodberry Grove DS0000010638.V292117.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. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodberry Grove Address 91 Wellington Road Bush Hill Park Enfield Middlesex EN1 2PW 020 8360 2214 020 8886 9296 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) Hapee Care Ltd Mr Kathiresu Cumareshan Mrs Janet Carol McGuigan Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Woodberry Grove is a care home registered to provide a service for 26 older people. The service has recently been granted registration to provide dementia care services. A respite care service is also provided. The stated aim of the service is to provide a high standard of individual care, support and a pleasing environmnet for all the residents to enjoy a good quality life. Woodberry Grove is a private care home owned by Mr Cumaresham of SSS Care Limited. Mr Cumaresham owns a number of other care homes in England. The service is provided in a large detached property with rear extension, that has been converted for use as a care home. There are eighteen single bedrooms and four double bedrooms. Bedrooms are on the ground, first and second floor with a shaft lift serving all three floors. In addition, there is a chair lift linking the ground and first floors. There are bathrooms on all three floors. There are two lounge areas and a dining room on the ground floor and a room on the second floor which is used by the hairdresser and can also be used by staff and service users as a sitting area. There is a garden to the rear which includes a grassy area with trees and shrubs as well as a paved area with seating for residents. Woodberry Grove is in an quiet road in an attractive residential area of Bush Hill Park, Enfield. It is close to local shops, a railway station and bus routes. The provider must make information available about the service, including reports, to service users and other stakeholders. Fees for the home range between £345.00 - £485.00 per week. Woodberry Grove DS0000010638.V292117.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 one day. The Registered Manager Janet McGuigan assisted throughout with the inspection. The Registered Provider, six service users, two relatives and two staff were spoken to on the day. Care, home and staff records were inspected, along with health and safety documentation. A pre-inspection questionnaire was received from the home. A tour of the premises completed the inspection. What the service does well: What has improved since the last inspection? The home has made excellent progress, meeting all requirements from the previous inspection. Care planning for service users with dementia has improved. Several medication requirements have now been met. The home’s medicines policy now covers self-administration of medication and situations where medicine is given covertly. New equipment for medication dispensing is place, and the home is due to change its contract to Boots to improve service. Medication temperatures are recorded and are consistently below 25 degrees. The home’s adult protection policies and procedures been updated and are now aligned with local authority policies and procedures, including sections on what to do in case of alleged abuse. The Registered Manager has undertaken a Train the Trainer course in adult protection and most staff have now been trained in this area. While no new staff have been recruited since the last inspection, recruitment procedures now include a from for pre-employment health screening. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 6 Staff training has moved along. The home has had a Workforce Development Training Analysis completed; a timetable for staff NVQ achievement has been drawn up, with more staff moving up to NVQ3 study and staff have been provided with comprehensive training in care planning. The home now produces a basic quality assurance report and kitchen temperatures are now checked and recorded in an orderly fashion. 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. Woodberry Grove DS0000010638.V292117.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 Woodberry Grove DS0000010638.V292117.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): 3 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Clearly written information about the home and the services provided are available to services users. The assessment procedures are sound. EVIDENCE: The atmosphere at Woodberry Grove is homely and relaxed. On the day of the inspection, positive relationships were observed between service users and staff. Feedback from the service users and one relative spoken to was that the standard of care is good. There were twenty three service users in the home at the time of the inspection and there have been two admissions since the last inspection. There is good information for prospective service users contained in the statement of purpose and the service users’ guide. Initial assessments give sufficient information from which to plan care and the assessment of prospective service users with dementia has improved. Relatives said that they participated in reviews. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 9 Service users spoken to who were able to describe the process, said that their needs had been assessed prior to admission. The home does not provide intermediate care. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 10 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive good care in the home. Care plans are sound and now cover dementia in more detail. Medication policies and procedures have been improved in the service users’ interests. However, the home must take care in the storage of medication. EVIDENCE: There were twenty three service users in the home at the time of the inspection. Three service users’ care plans were inspected. These were clearly laid out and easy to understand and included good profiles and information. The service users’ care needs were well covered and there are now more detailed dementia care assessments in place. The care plans set out clear goals and actions to be taken to meet these goals and were regularly reviewed. Staff have received in depth training on care planning, which the Registered Manager said will enable them to produce care plans for the service users whom they keywork. Risk assessments in all areas of care are good and regularly reviewed. District nurses come in twice a day and provide good back-up the service users. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 11 Regular preventative health care visits take place regularly and recorded appropriately. The medication policy and procedure has been improved and now includes section on self medication, controlled drugs and the disguising of medication, if necessary. However, the Registered Manager said that there is no one currently falling under these categories at the moment. The Registered Manager said that the home had reviewed its medication arrangements and has changed to a contract with Boots. New equipment (cups, for example, for dispensing medications) have been obtained and the documenting the receipt of medication has been improved. The medication room temperatures have improved and are now maintained under 25 degrees Celsius. There is a dedicated refrigerator for the storage of medication requiring refrigeration which is being maintained between 2 and 8 oC. However, this found unlocked and it is required that this always be kept locked. MAR charts were examined and were in order. Senior staff are currently receiving medication training but there are still some staff who require training, as required under Standard Thirty. All the service users and relatives spoken to said that the staff treated them well and that their rights were respected. They were very positive about the quality of care given in the home. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Activities and options for outing continue to improve in the service users’ interests. Service users are supported to have good family contact. Food remains pleasant, plentiful and nutritious. EVIDENCE: Service users mainly followed their own interests during the inspection, which including watching television and reading. There have been several more trips outside the home have expanded since the last inspection. The most popular activities have been visits to Kew Gardens, the local garden centre, seaside trips and visits to the local theatre, to musicals, the pub and restaurants. Activities in the home remain basic but most service users participate as well as they can. There is a general division between the two lounges in the home, with one lounge mainly occupied by service users who prefer to chat throughout the day and the other by people who prefer to watch television and do group activities. The garden is also well used by most people in the summer, with barbeques being very popular. Visiting hours are not limited and several service users go home regularly. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 13 The lunch on the day of the inspection was healthy and nutritious, with choices available. Four weekly cyclical menus indicate that the home does a particularly good job of providing cooked meals three times a day. For example, porridge and eggs are available for breakfasts and lighter evening meals like quiche and salad, pasta bakes and chilli con carne are offered in the evenings, to complement full cooked meals at lunchtime. The cook has been in the home for many years and has a good knowledge of the service users’ preferences. Service users’ cultural needs are considered and several described the food as “excellent”. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements to protect service users are improved, particularly in the areas of staff training and policy and procedural guidance to deal with incidents or allegations of abuse. EVIDENCE: There have been one complaint received since the last inspection, which was appropriately investigated and responded to. The complaints procedure is now quite robust. Most staff have now received adult protection training and the Registered Manager has completed a Trainer the Trainer course in adult protection in order to train her staff. The adult protection policy and procedure has now been updated and includes actions to be taken in incidences of alleged abuse and generally corresponds with the local authority’s policies and procedures. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is undertaking a good refurbishment programme at present and the service users are pleased with this development. Minor repairs are required. EVIDENCE: The home has had considerable refurbishment since the last inspection. Bedrooms have been repainted and fully refurbished with new beds, furniture and curtains. A new dishwasher, fridge and freezer have been purchased. The garden environment has been improved with new garden furniture, at the service users’ request. The hallways are currently being painted and a new conservatory is due to built. The Registered Manager showed the inspector three vacant, adjacent rooms, which the home plans to convert into two ensuite bedrooms. Minor repairs are required to a cracked window panes in rooms 11 and 12 and to an electrical socket in room 16. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 16 A cleaner works at the home five days per week, and a weekend cleaner does the weekends. The home is in the process of recruiting for a cleaning position. Hygiene and cleaning standards were good and the home was free from unpleasant odours. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 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 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, 29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The established staff team works well to support the service users and there are sufficient staff in the home. Improvements and extensions of staff training will help staff support the service users more skilfully. There are still some areas of training that require updating. EVIDENCE: Two staff members and the Registered Manager and Registered Provider were spoken to on the day of the inspection. Service users were very positive about the staff: one said “they always cheerful and kind and never miserable to you”. Many staff have worked at Woodberry Grove for a long time. Interactions observed between the staff team and with the service users were very relaxed, but professional. The Registered Manager works closely with the staff and the service users on a day to day basis. Staff said that morale was very good and that they were well supported, formally and informally. Health check forms have been completed for all staff and are available for new staff when they start. All new staff receive a thorough induction, both formally and informally delivered and including self directed learning. One new staff member has have been recruited since the last inspection but is yet to start. Her file was in good order and all pre-employment checks completed. The home has a low staff turnover. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 18 There were twenty three service users in the home on the day of the inspection and general feedback indicted that the staffing levels are sufficient for the needs of the service users. Staff hours are monitored weekly to ensure that the specific needs of the service users are met, particularly those service users with dementia. Staff training is improved since the last inspection. The home has had a Workforce Training Needs Assessment and has taken forward the recommendations of this review in planning future staff training. A timetable for staff NVQ progress has been produced and a adult protection training delivered. In line with the needs of the service users, staff have received training in diabetes management and incontinence management. Although there is good progress in developing a training programme, there are gaps in statutory training and it is required that all staff received moving and handling training and medication training at least annually. Staff also require food handling training. The Registered Manager has located care plan training and all staff have participated in this comprehensive modular training to enable them to produce and review care plans. This enables the Registered Manager to delegate work that has been previously done only by herself. She is currently working hard on the Registered Managers’ Award and intends to do the RMA in Care after this course is finished. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 19 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, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home continues to benefit from the leadership of the Registered Manager. Quality assurance processes are in development. Health and safety of service users is generally well protected. EVIDENCE: The Registered Manager has commenced the Registered Manager’s Award. All the service users and staff were positive about Janet McGuigan’s management style and support. The home has good systems for supporting the service users who require help with their finances. A quality assurance process has been designed and implemented. The results of the surveys were positive and requests for more spicy foods and more garlic have been actioned. Service users were offered the option of telephone in their rooms but they all declined. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 20 Supervision records inspected showed that the staff received two monthly, comprehensive supervision. Accident and incident records were inspected but some contained very information on the nature of an incident or accident. It is required that these be completed more thoroughly. contained only minor falls since the last inspection. All health and safety certificates were checked and found to be in order. Fire safety procedures and records were checked and were in order. Regular fire drills and checks take place. The home has had a recent visit from the Fire Service, who were happy with the fire protection systems. The recording of food temperatures has improved considerably and is now orderly and systematic, meeting a requirement from the last inspection. Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 X 3 3 X 2 Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 22 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. 2. 3. 4. 5. 6. 7. Standard OP9 OP19 OP19 OP30 OP30 OP30 OP38 Regulation 13(2) 13(4) 13(4) 18(1) 18(1) 18(1) 12(1) Requirement The Registered Person must ensure that the medication fridge is kept locked at all times. The Registered Person must ensure that window panes are repaired in rooms 11 and 12. The Registered Person must ensure that am electrical socket is repaired in room 16. The Registered Person must ensure that all staff receive training in medication. The Registered Person must ensure that all staff receive training in food hygiene. The Registered Person must ensure that all staff receive training in moving and handling. The Registered Person must ensure that incidents and accidents are fully recorded. Timescale for action 30/08/06 30/08/06 30/08/06 30/08/06 30/08/06 30/08/06 30/08/06 Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Woodberry Grove DS0000010638.V292117.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!