Inspection on 17/05/05 for Woodbury House

This inspection was carried out on 17th May 2005.

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

Woodbury House 19/08/08

Woodbury House 25/07/06

Woodbury House 17/10/05

Woodbury House 17/11/04

Woodbury House 07/05/04

Woodbury House 26/04/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Woodbury House Joulding Lane Farley Hill Swallowfield RG7 1UR Lead Inspector Sandra Grainge Unannounced 17 May 2005 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. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodbury House Address Joulding Lane, Farley Hill, Swallowfield, RG7 1UR 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) 01753 869777 Exceler Healthcare Services Ltd Vacancy Care Home with Nursing 45 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No Date of last inspection 17 November 2004 Brief Description of the Service: Woodbury House Care Centre is owned and managed by Exceler Healthcare Services,a part ot the Ashbourne Group. The Service is registered to provide nursing care for up to 45 older persons. The property is a large converted country house that has rural views across the Berkshire countryside on the outshirts of Farley Hill near Reading. There is no public transport to the area;ample car parking spaces are available on the property. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home that was carried out over 8 hours by a locum inspector. Previous correspondence and requirements made of the home were considered prior to the inspection visit. Outcomes for service users from issues previously raised were evaluated against the action plan sent by the Area Manager. There was evidence that the action plan had been followed and all requirements had been met. The home is currently without a Registered General Manager and action is being taken to employ one. In the interim, the Home’s Care Manager has been in charge with support from the Company Area Manager. Service Users, who like to be called residents, all expressed satisfaction with the care and service being given to them in the home. The visiting relatives who were able to speak to the Inspector endorsed this; regrettably the time available did not allow for contact with all the relatives Care records, the assessment process for admission to the home and record keeping were all inspected. Employment and other statutory records were included. A tour of the building was made; not all rooms were inspected in detail on this occasion. What the service does well: What has improved since the last inspection? Considerable work had been done to meet the requirements of the previous inspections. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 6 Residents felt that the home was always clean and tidy and they enjoyed the activities that were made available. The practice of staff recruitment and training had been improved to meet the national minimum standards and so residents were assured that they are safe in the hands of the carers. One relative commented that the “Home does its job well” There was evidence that staff meetings are being used to improve team working and so give residents a standard of consistent good care. Equipment for infection control good practice was available and in working order. A recorded system of management of health and safety, food hygiene, quality control, staff recruitment, training, supervision and internal auditing was now in place. 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. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 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 H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 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) 1,3,and 5 Prospective Residents were suplied with information about the home and the service that it offers prior to being admitted. An invitation to visit the home was given to the resident and relatives. The acting Manager completed an assessment of need prior to admission. EVIDENCE: Residents confirmed that they had received a copy of the statement of purpose for the home and the user’s guide. Copies were available in the Hall, together with a folder of thank you cards and comments that had been sent by relatives. The file of the person most recently admitted to the home contained completed assessment forms and detail of the invitation to visit the Home. Due to frailty she was unable to accept this, so it had been accepted by her relatives. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 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 and 11. The residents health , personal and social care needs are assessed and monitored. EVIDENCE: Each resident had a plan of care. Those sampled contained detail of the action that care staff must take in order to meet the assessed needs of the resident. Plans were revised and updated. There was evidence of comprehensive recorded assessment of nutrition, risk, tissue viability, continence, and mental health needs. Following the previous inspection detail of social and recreational activity had been included in the records. Recent reassessment of residents’ needs had confirmed change and it recorded that two people had developed mental health needs that the service is not registered to meet. The outcome of this situation is to be reported to the CSCI. Practice of administration of medication was observed at lunchtime. The record charts and practice seen were satisfactory; the standard was not met in full because staff were using a bottle of medication prescribed and labelled for one resident as a “stock bottle” for others also taking the same medication. Residents commented that they felt that they were treated with privacy and respect. In practice this was confirmed with the exception of the use of a bath H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 10 list that was displayed on the wall of the shared bathroom. The care manager agreed to change this practice immediately. The inspector did not have discussion with residents or their relatives about care of the dying; however, there were policies and procedures in place for this and the care given to several very ill residents demonstrated that staff were competent and experienced. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 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 standard(s) 13 and 15 Residents were were able to maitain contact with family and friends when they wished. A balanced nutritious diet was offered. Residents confirmed that they were able to have hot and cold drinks when they wished. EVIDENCE: Residents confirmed that they were able to receive visitors in the home when they wished. The only limitation on visiting was due to the remote location of the home. No public transport was available; however some relatives had arranged to share car journeys. The contracted catering company and the Manager of the Home plan menus. Breakfast menus had been changed in response to recent residents’ meeting and survey. Special themed events were offered that were enjoyed by the more able residents. All the rooms visited contained a glass and jug of cold water or juice. Staff were available to assist residents who needed help to eat and drink. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 12 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) 16 and 18 . Residents were aware of the complaints proceedure and felt that if they had concerns these would be heard and a suitable response made. They were protected by trained staff who were able to demonstrate that they knew the correct action to take in response to any allegation of abuse. EVIDENCE: The company’s complaints procedure was available in the entrance hall and further detail was included in contract papers. Relatives were aware of this. Since the last inspection senior company staff had reviewed the management of complaints in the home. A system for recording concerns and responding to complaints was in place. No complaints had been received since February. Staff confirmed that they had received training to make them aware of issues of abuse of vulnerable adults. They were able to describe to the inspector the action that they would take if they suspected that this was occurring. The area manager is to follow up and report on the outcome of reporting the actions of a member of staff, who briefly worked in the home last year, for inclusion on the Protection of Vulnerable Adults register. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 13 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, 22,23,24,25 and 26 Residents live in a safe well maintained environment that has been assessed and adapted to meet thair needs and they have the equipment that they need . EVIDENCE: The premises have been recently been reassessed to ensure that the converted building is suitable for use by those who live in it. It was apparent that each room is individual and contains the personal possessions of the occupant. A continuous programme of redecoration and refurbishment is in progress. A programme of planned checks and maintenance is recorded and protects resident safety. Another employee is being recruited to assist with this, the redecoration programme and the garden upkeep. Laundry facilities were adequate to meet infection control standards and there were arrangements in place for the disposal of clinical and other waste. As a H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 14 result the home was clean and odour free. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 15 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, 29 and 30 Required numbers of staff were on duty and residents stated that they felt safe in the care of the staff. EVIDENCE: Residents were satisfied with the overall numbers of staff to care for them. They expressed no concern about staff shortages and most were not aware that the Registered Manager had left. Staff rotas were examined and found to be in line with previous requirements. Staff recuitment was examined and the proceedures used for recent employees was found to be in accordance with the National minimum standard. Once recruited, the staff had been given the necessary induction and ongoing training. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 16 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) 33, 34, 36 and 38. Standards 31 and 32 were not relevant because the service does not have a Registered Manager. There was a Company management structure in place to monitor quality of service offered to residents. This was suported by budget and review. Accounting and financial strategies were in place to safeguard the welfare of the residents. Following the previous inspectionthe records of staff supervision and development had been kept. Health ,welfare and safety of residents and staff was protected by management strategies. EVIDENCE: H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 17 In the absence of a Registered General manager the home has been in the charge of the Care Manager who has worked there for several years. Her hours of work are supernumery to the required quota of staff for the home. The Company’s experienced Area Manager, who has recently joined the organisation, has supported her. Staff practice for moving and handling, fire safety, first aid, food hygiene and infection control have all been monitored. The use of bed rails has been risk assessed and reviewed as part of the process for ensuring health and safety. As a consequence rails are used less frequently; this was of some concern to one resident and her relative because she had grown accustomed to the safety she felt in the protective confine of the bed rails. With their permission this issue was referred to the acting Manager for resolution. H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 18 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 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 N/A N/A 3 3 x 3 x 3 H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? 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 4 Regulation 4 (3) b Requirement Send action plan to demostrate how the identified mental health care needs of two specific service users will be met. Medication prescribed for a named service user must not be given to anyone else. Report on outcome of notification of previously employed member of staff to POVA register. Appoint and register a manager for the Home Make repairs to the WC for use of catering staff. continue to focus on infection control practice and include storage of cleaning equipment. Timescale for action one month 2. 3. 4. 5. 6. 9 18 31 38 38 13(2) 37,(1),g 8 16 (j) 13(3) immediate two months two months immediate immediate 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 Good Practice Recommendations H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 2nd Floor, 1015 Arlington Business Park Theale Berks RG7 4SA 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 H52-H01 S11026 Woodbury House V225842 170505 Stage 4.doc Version 1.30 Page 21 - 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!