Inspection on 17/10/05 for Woodbury House

This inspection was carried out on 17th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 17/05/05

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 Berkshire RG7 1UR Lead Inspector Stewart Mynott Unannounced Inspection 17th October 2005 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 Woodbury House DS0000011026.V253495.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. Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodbury House Address Joulding Lane Farley Hill Swallowfield Berkshire RG7 1UR 0118 9733885 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) Exceler Healthcare Services Limited ***Post Vacant*** Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th June 2005 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. Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted by two inspectors, which took place during the day and lasted for 7 hours. Most of this inspection was spent with service users and staff observing the daily life and care practises within the home. Nearly half of the service users were spoken to as well as most of the staff on duty to gain their views about the home. In addition views were sought from three visiting relatives, a district nurse and the home’s general practitioner. Some time was spent with the new general manager and administrator during the course of the day. Records relating to the care of service users and some of the homes records were also examined. A complaint that was received at the CSCI office from a relative was also investigated. The complaint was about some concerns regarding the care of one of the service users. The home had already made efforts to investigate, address and resolve the issues that were raised. The investigation conducted by the CSCI reached the same conclusion as the home’s investigation agreeing that one element of this complaint was substantiated. This was in reference to the lack of a glass to drink from in the service users room, noted during the relatives visit. Checks made during this inspection revealed that glasses and jugs were readily available in service users rooms. Staff were aware of the complaint and were clear about the importance of service users access to drinks when in their private rooms. What the service does well: Woodbury House is a clean, well-maintained and pleasant care home with a relaxed and homely feel. Many service users and all visitors spoken to confirmed that the staff are kind and caring. Observations during the day confirmed that morale within the team is good and staff were professional, attentive and in sufficient numbers. The home retains its own staff team with very little reliance in using agency staff. The recording and monitoring of service users personal and health care needs is of a high standard. There is a supportive working relationship with the home and the local GP surgery, and as such there is a good system to monitor health care needs of service users. Both the GP and a District Nurse were complimentary and positive about the standard of care provided at the home. Service users confirmed that they feel that they are able to make choices in their daily life and are able to exercise control. Staff were observed to attend to service users requests and wishes during the day and to support their Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 6 choices. An activity program is made available and service users are able to choose to participate in these activities if they wish. What has improved since the last inspection? 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. Woodbury House DS0000011026.V253495.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 Woodbury House DS0000011026.V253495.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 Service users needs are fully assessed to ensure they can be met by the home prior to admission. EVIDENCE: A service user and their relative discussed their experience of the admission process into the home. The service user had only very recently been admitted. An assessment had been completed through the care management process and the homes care manager had also visited and completed a needs assessment. The relative had the opportunity to visit the home beforehand and was “impressed” with the home and was confident that all needs could be met based on the information that they had received. The assessments were viewed on the care file and seen to be detailed and complete. Woodbury House DS0000011026.V253495.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 and 10 Service users personal and health care needs are fully met and their needs are set out in a comprehensive plan of care, which is kept under review. Service users are treated with dignity and respect although some further improvements could be made to address comments made by service users to the inspectors. EVIDENCE: Ten of the service users care files, who were spoken to during the inspection, were examined in detail. Service users confirmed that they were not directly aware of their care plans but assumed that detailed records would be kept and they were satisfied to have no further involvement. All of the care records examined contained detailed information in relation to personal, health and social needs as well as daily records and other supporting documents. The care plans and ongoing assessments document is of a corporate design and information was recorded in a clear and straightforward manner. In all care files this information was recorded in detail with additional individual comments that included personal preferences and demonstrated a good understanding of the individual. The care plans and assessments had been reviewed on a monthly basis in all cases. Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 10 Service users spoken to described that their felt their health needs were well attended to by the nursing staff and that there was access to their GP and other local NHS facilities. Service users confirmed that all treatment occurs in private. The care manager described that the GP reviews three service users health needs each week during his weekly visit and the home has a positive relationship with the surgery. The GP confirmed this system of review and confirmed a good working relationship and that he felt and his confident in the nursing team. A district nurse from the same surgery has also confirmed a good relationship and commented “staff are always willing to help and listen to advise when working with us”. The district nurse also gave an example of where the care provided by the home had contributed to an improvement in a service users health. Staff were observed to be professional and caring during the inspection with some good care practises observed. Service users confirmed that they felt treated with respect and dignity by the staff team. Most service users were positive about the staff and described them as “caring”, “considerate” and “kind” and had a good knowledge of their individual needs. A number of service users did comment that care staff were attentive and always answered call bells. However in busier times when service users had to wait for staff, service users felt that the staff team should acknowledge this out of politeness. Service users confirmed that they received their post unopened and could use a telephone if needed, and had the option of having their own private line if required. Most service users confirmed that they are appropriately addressed by staff however two service users commented, and one of the inspectors experienced one member of staff addressing everyone as “darling” and this may not always be viewed as appropriate. Woodbury House DS0000011026.V253495.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, 14 and 15 Service users are able to exercise choice and control over their lifestyle and daily activities and routines and are supported by the staff team. A response to the negative comments made by service users in regards to the quality of the food is required with a subsequent plan of action implemented to address this area. EVIDENCE: Service users confirmed that they were happy with the lifestyle within the home and that they were able to have some choice and control over their personal routines and daily experiences. Through discussion with service users and observations it was noted that routines of daily living varied for each service user. Service users were able to choose when they wished to socialise or spend time in private in their rooms. Staff were observed to assist service users in exercising their choices during the day. Service users confirmed they are able to choose their own activity and interests during the day. Observations made during the day supported this. The home has an activity coordinator and a program of group activities had been planned for this month. This program of events was viewed in communal areas and in some of the service users bedrooms. The activities were varied and during the day group activities in the lounge area were observed during which service users confirmed their enjoyment. Some service users confirmed Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 12 that they use a mobile library service and have daily newspapers. Recreational activities outside the home also occurred including a drink in the nearby pub, which several service users commented that they really enjoy. Service users care records included information about life history and interests. Time was spent with service users during lunchtime. Service users confirmed that they had a choice from the menu and that the portions were sufficient. They also commented that were happy with the amount of assistance staff provided during meal times and all meals were unhurried. Some service users required their meals pureed and it was noted that these were served attractively and staff offered assistance to those whom required it in a discreet and supportive manner. Staff were observed to be observant and attentive to service users, however it was observed that staff do not always explain what the meal is when serving it to a service user. This is not appropriate; particularly for service users receiving purred meals or have some degree of memory or sensory impairment. A significant number of service users were clear in that they were dissatisfied with the food served at the home and that they had voiced their opinions. Service users confirmed that they did not know the chef and wished to express their opinion although were concerned that despite prior comments no change would occur. Some of these opinions had been recorded in a feedback book, although action taken as a result of these comments was not evident. The chef was spoken to and was aware of the comments in this book and acknowledged that some service users were not happy. The chef agreed to arrange a meeting with service users to tackle this issue to attempt to identify any common issues. It is a requirement that the outcomes of this meeting and subsequent plans to improve in this area are sent to the CSCI. Woodbury House DS0000011026.V253495.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 Further development to ensure that all service users complaints are recorded and investigated as per the provider’s policy is required. The in house complaints procedure should be reviewed and simplified to improve accessibility and clarity of who to complain to for service users and their visitors. EVIDENCE: There is a “customer complaints and comments” policy and procedure within the home and on display at the front entrance. Service users and relatives confirmed that if they were unhappy then they would make a complaint. Service users and visitors described a number of people that they would complain to. No one spoken to was aware that their complaint should be directed to the general manager as per the policy and during a subsequent discussion with the general manager it was suggested a more accessible in house complaints procedure could be developed. Staff were aware that they would try and resolve any complaint and would report these to the care manager. The complaints record book was examined and two complaints were received since the previous inspection. Both complaints had been thoroughly investigated with speedy responses to complainants. One of these complaints had also been referred to the CSCI and this was investigated in detail during the initial part of the inspection. The outcome from the CSCI’s investigation agreed with the general managers response to the complainant. Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 14 Service users had commented about their dissatisfaction with the food and some had also clearly commented that they had complained but felt “no-one listens” and that “there would be no change”. These comments should have been recorded as complaints and investigated as such with service users being given the confidence that their views are taken seriously. This is regarded as a serious shortfall and it is a requirement that all complaints made by service users are investigated and resolved in line with the provider’s policy. Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 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): Standards 19 to 26 were not assessed during this inspection. EVIDENCE: Woodbury House DS0000011026.V253495.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): 27 Service users needs are met at all times by a sufficient number of staff on duty. EVIDENCE: During the inspection there was in addition to the general manager and care manager, two nurses and five care assistants and an ancillary team on duty to support the home. The rotas were examined over the prior four weeks and staffing levels were found to be the same. The management confirmed there was now little reliance on agency staff. Service users and visitors spoken to felt there were sufficient staff to meet their needs. Observation during the inspection also confirmed these views. Woodbury House DS0000011026.V253495.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): 31, 32, 33 and 35 The home’s general manager and management team demonstrate that they are able to manage, lead and develop the home for the benefit of service users. The manager is required to submit an application form to be registered with the CSCI in respect of this service. The homes financial procedures protect service users. A company representative is required to complete monthly visits to check the quality of service provided at the home and a copy of these reports are to be sent to the CSCI. EVIDENCE: The home now has a permanent general manager who took up this post in July. An experienced care manager who has been recently promoted supports the general manager. It is evident that both the general manager and care manager have the experience to effectively manage the home. Evidence from various discussions during the inspection demonstrated that the general manager has a “grasp on the home” and some of the changes discussed were Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 18 viewed as positive. Staff commented that they felt teamwork has improved and were positive about the management team; morale in the team appeared to be good. The manager is required to submit an application to register as the manager with the CSCI for this service. The manager stated that she intends to submit this application in the near future. The homes administrator explained the homes system and policy for dealing with service users monies. There are individual records for service users personal allowances, which are clear and include receipts and the administrator and manager had signed each transaction. There were secure facilities for the safe keeping of valuables as required by service users. It appears that there have not been regular unannounced visits made by a company representative under regulation 26. These visits are required to be on a monthly basis to check on quality of the service provided within the home. A copy of these reports is required to be sent to the CSCI after each visit. Woodbury House DS0000011026.V253495.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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 X X X Woodbury House DS0000011026.V253495.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. 1 Standard OP10 Regulation 12 (4)(a) & (5)(b) Requirement The registered person ensures that all staff understand and observe the arrangements for ensuring service users dignity, respect and consideration to include appropriate terms of address, serving meals and acknowledgement when service users have had to wait for staff to answer call bells in busier periods. The registered person must send results of the proposed meeting with service users and subsequent plans to improve the quality of food. The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual requirements. The registered person ensures that all complaints from service users are dealt with promptly and effectively. Timescale for action 30/11/05 2 OP15 16 (2)(i) 30/11/05 3 OP16 22 (1)(2) & (3) 30/11/05 Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 21 4 OP31 8 The registered person ensures that the general manager submits an application form to become the registered manager in respect of this service. That the registered person ensures that an unannounced visit to the home occurs on a monthly basis to comply with regulation 26, and a copy of the report is sent to the CSCI. 15/11/05 5 OP33 26 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP16 Good Practice Recommendations The registered provider further develops the in house complaints procedure to ensure that it is simple, clear and accessible and in a format that service users can understand. Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Berkshire Office 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 Woodbury House DS0000011026.V253495.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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