CARE HOMES FOR OLDER PEOPLE
Woodbourne 1 Oakwood Rd Horley Surrey RH6 7BZ Lead Inspector
Lisa Johnson Announced Inspection 28th November 2005 09:00 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 Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Woodbourne Address 1 Oakwood Rd Horley Surrey RH6 7BZ 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) 01293 822829 Mr Rohana Silva Mrs Sarojini Devi Silva Mr Rohana Silva Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th April 2005 Brief Description of the Service: Woodbourne is a detached property set in a residential area close to Horley town centre. Services and accommodation are available for six men and women with mental illness. The service users are relatively independent in terms of personal care needs but require support and monitoring to maintain active lives in the community. Bedrooms are provided on the ground and first floor, all are single and half have en-suite facilities. The communal areas comprise of two lounges (one of which is a designated smoking area) and a kitchen/dining room. There are good staff facilities available including two sleeping rooms. Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second inspection carried out in 2005/2006. The announced inspection took place over four hours and was carried out by one inspector. Mr and Mrs Silva were present as representatives of the home. A full tour of the premises was undertaken and care plans policies and procedures and other required documentation was sampled. The inspector spoke to three service users. A comment card was received from one resident, two from relatives/friends and two from health care professionals. These comments are reflected in this report. This was a positive inspection. The inspector would like to thank the service users and staff for their assistance and cooperation during this inspection. What the service does well: What has improved since the last inspection?
Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 6 Medication records were sampled and all medication administered was signed for. The out of date dressings have been disposed of and medication training has been accessed. Staff who are employed as carers administer the medication. Paper that was stored in the smoking room has been removed and a carpet has been replaced in one downstairs bedroom. A requirement to box in the pipes in the downstairs en-suite toilet has been completed. Ventilation has been improved in the smoking room with the installation of an extractor fan. The registered manager has responded to the recommendation in respect of making the homes protection of vulnerable adult policy a stand-alone document based on the local authority protection of vulnerable adults procedure. The home has achieved the minimum ratio of fifty percent trained members of care staff (National vocational qualifications level 2 or above) being obtained. 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. Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 Pre admission assessments were completed and trial visits accommodated to “test drive” the home. EVIDENCE: Since the previous inspection a new resident has been admitted to the home who was currently staying on a trial period and it was clear that pre admission assessments were completed and a care plan had been implemented. Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9 & 11 The health and personal care needs of residents were being met and set out in an individual plan of care. The home is able to demonstrate that goal plans are reviewed and that residents are involved in the review process. Residents are protected by the homes medication policy and procedures. Policies and procedures for handling death and dying are in place EVIDENCE: Each resident has a completed care plan, which has been reviewed and based on assessment. Plans sampled were detailed and structured with individual goals. Plans have been signed by residents where possible and key workers. Residents are supported by a range of health care professionals including access to a local GP, social workers, care managers and community nurses. Comments received fro health professionals confirm that the home works in partnership with them, care plans are followed and that staff demonstrate a clear understanding of the care needs of residents. Medication records were sampled and were maintained appropriately. Items that were found out of date have been disposed of. The home has recently
Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 10 received a visit from the pharmacist and this report was examined and was satisfactory. The pharmacist carried out training during this visit. A recommendation was made that the registered manager should consider making a photograph of each resident and a staff signature list available of all staff trained to administer medication with the homes medication and administration records. Discussion has taken place with each resident in respect of his or her personal wishes with regard to dying and death and what formalities are to be observed. Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Residents were offered and supported with a range of recreational and social activities. Residents are supported to exercise choice and control over their lives. Residents were able to maintain contact with family, friends and local community as they wish. Residents were offered a well balanced and choice of meals. EVIDENCE: Residents are supported to be as independent as possible and individual preferences were accommodated. It was pleasing to see one individual participating in household activities such as clearing the dishes and peeling vegetables for the meal. During the inspection one individual was heard playing the piano which he has in his bedroom and was clearly enjoying this interest. Residents have access to community facilities with residents going to the local shops and cafes, library and car boot sale which are close by. Day trips to the coast have taken place and the home holds barbecues in the summer. Holy communion takes place every two weeks. Residents maintain contact with relatives by visits, writing letters and telephone. A pay phone is in place for the use of residents. Comments
Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 12 received from relatives confirm that they are made to feel welcome when they visit the home and are able to visit their relative/friend in private. Menus were sampled and were varied with individual preferences and choices accommodated and lunch was nutritious in content with a variety of sandwiches and salad being offered. There was a relaxed and unhurried atmosphere and residents spoke highly of the meals provided. Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 The home is able to demonstrate that there is an accessible complaints procedure. Resident’s legal rights are protected. Written policies and procedures were in place to ensure that residents are protected from abuse. EVIDENCE: A complaints procedure was available and residents spoken to knew who they could approach if they had any concerns. Residents spoken to confirm that were happy living in the home. The inspector spoke to one resident who had recently moved in to the home he said “Its good here”. Comments received from relatives confirm that they are aware of the homes complaints procedure and are happy with the overall care provided. Residents had the opportunity to take part in the electoral process. The home has now amended the homes protection of vulnerable adult procedure so that is a stand-alone policy with information being cascaded to staff. Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 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): 19,20,23, 24 & 25 The home is able to demonstrate that it provides a homely, well-maintained, clean and safe environment for service users to live in. Bedrooms were well furnished and service users had their own possessions around them. Residents live in a safe and comfortable home to live in which is clean and hygienic. EVIDENCE: The home is in close proximity to Horley Town centre and externally the home is maintained in good decorative order, which is in keeping with the local community. It is strongly recommended that the entrance gate should be attended to or replaced at the front of the house as it was found difficult to open. The registered manager stated that he is currently pursuing this issue. The home is well maintained internally and has a homely atmosphere. A recommendation was made in respect of the upstairs bathroom window, which would benefit from a blind being installed. The registered manager stated that
Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 15 the smoking room was painted not long ago but is planning for this to be repaitented and a recommendation was made that this should be completed. Bedrooms are large, spacious and decorated to a good standard and are appropriately furnished. One resident had hid his on piano in his room. Records are available of routine maintenance and checks including water, heating, electrical certificates and emergency lighting. Adequate ventilation is available. The home was cleaned to a high standard and was hygienic. Infection control procedures were available. Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29 & 30 Residents are protected by the homes recruitment policies and practices. Staff are supported to undertake training and development to ensure that they are competent to carry out their job. EVIDENCE: Two staff personal files were sampled and were maintained in good order with all the required information available. There was evidence to support that staff attend and receive training and development including food hygiene, infection control, medication training, health and safety and seven staff hold a first aid certificate. One person has attended training in dual diagnosis in mental health. The home has complied with the minimum ratio of 50 trained members of care staff (NVQ 2 or equivalent) being achieved. Discussion took place in respect of the validity of nurse qualifications without registration and further qualifications that may need to be acquired. Since the inspection further advice is being pursued by the registered manager. Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The manager has implemented a quality assurance system based on seeking the views of residents and through a process of self-auditing. The rights and interests of residents are promoted by the homes record keeping, policies and procedures. Health and safety procedures within the home protect service users from harm. EVIDENCE: The home carries out an annual survey by gaining feedback from residents and the manager has updated the forms. It was also pleasing to see that home carries out a programme of regular self-auditing in the home and evidence of this was sampled. The home holds resident’s meetings and minutes of these discussions were recorded. Comments received from relatives and health professionals indicate that they are made aware of the inspection report.
Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 18 A comprehensive range of policies and procedures were in place, which was sampled including resident’s access to records and the code of conduct set out by the General Social Care Council. Staff are made aware of policies and procedures in the home and were signed by staff and discussed in staff supervision. A range of health and safety policies have been implemented including health and safety risk assessments, fire risk assessments including evidence that regular equipment checks and fire drills take place. Accident records were maintained appropriately and hazardous substances were stored correctly Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 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 3 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X 3 3 Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP 9 Good Practice Recommendations The registered manager should consider supplying a photograph of each resident and a list of staff ho are able to administer medication with the homes medication and administration records It is strongly recommended that the registered manager should consider replacing the gate at the front of the house. The registered manager should consider having the smoking room repainted. The registered manager should consider installing a blind in the upstairs bathroom. 2 3 3 OP 19 OP 19 OP 19 Woodbourne DS0000041738.V256838.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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