Inspection on 16/08/06 for Woodcote Hall

This inspection was carried out on 16th August 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

Woodcote Hall 11/11/09

Woodcote Hall 27/01/09

Woodcote Hall 08/05/08

Woodcote Hall 18/04/07

Woodcote Hall 01/03/06

Woodcote Hall 04/10/05

Woodcote Hall 30/03/05

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE Woodcote Hall Woodcote Newport Shropshire TF10 9BW Lead Inspector oy Hoelzel Key Unannounced Inspection 16th August 2006 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 Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 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. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodcote Hall Address Woodcote Newport Shropshire TF10 9BW 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) 01952 691383 01952 691635 Select Healthcare Limited Care Home 56 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (56) of places Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate a maximum of 56 Older Persons and a maximum of 1 Younger Adult. The home may accommodate a maximum of 28 users requiring nursing care. The home must provide for 56 service users:08.00-14.00 14.00-22.00 2 RGNs 2 RGNs 6 Care Assistants 6 Care Assistants One named resident as per discussion of 13.09.05 22.00-08.00 1 RGN 5 Care Assistants 4. Date of last inspection 1st March 2006 Brief Description of the Service: Woodcote Hall is a care home providing accommodation, personal and nursing care for up to fifty-six older people. It is privately owned by Select Healthcare Ltd. and is one of a number of care homes within the company. Weekly fees range from £337.47 - £518.40. The Home is set within it’s own grounds and sited directly off the A41, south of the town of Newport. There is a good selection of communal use rooms, most bedrooms are single occupancy and some have en suite facilities. There is a passenger lift to access the first floor. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the first of key inspections for 2006/07 and took place over five hours on Wednesday 16th August 2006. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty three of the thirty eight National Minimum Standards for Older People were inspected. Forty eight people are currently living at the home; and throughout the time of the inspection were observed to be accessing all areas of the home. The acting manager was on the premises supported by two registered nurses, six care staff and domestic and catering staff. Four case files were selected for case tracking, relevant documents were inspected, discussions were held with service users, visitors, members of staff, and the acting manager. Observation was made of the various daily activities and a tour of the premises was conducted. What the service does well: What has improved since the last inspection? A first level nurse has been recruited for the position of registered manager. Two bathrooms have been refurbished, with work currently being undertaken on the remaining bathrooms. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 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 Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 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): OP 3,6 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The home has produced a statement of purpose, which sets out in detail all aspects of the service provision. This is clear, jargon free, easy to understand and gives people a very clear understanding of what they can expect of life at the home. EVIDENCE: The home has produced a comprehensive and extensive statement of purpose detailing all aspects of the service provision. The document is readily available and reviewed and revised at regular intervals. The case file of a prospective service user included a pre admission assessment of the person’s individual need, undertaken by the local authority and/or primary health care trust and the home. The nurse who carried out the assessment explained the process and discussed the required equipment that has been identified to fully meet this persons needs. The four case files selected for inspection also contained the preadmission information. The home does not offer an intermediate care service. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 9 Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 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): OP 7,8,9,10 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are sensitive to the individual needs of each service user and meet these in a professional manner. There is a care planning system in place, some amendments are needed to ensure that any changes are recorded to ensure that the needs of service users are fully met. EVIDENCE: Four case files were selected for inspection each containing a plan of care following the assessments of daily living, risk assessments and monitoring tools. The manager is carrying out monthly audits of all care plans. The care plan for one person that was completed in June 2006 did not have the signature of the service user and/or representative and had not been reviewed since the plan was formulated. All four care plans had not been reviewed on a monthly basis Some documents in the case files had been signed by the service user and/or representative. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 11 The carer’s daily report, records all interventions offered to service users during the day, this offers a clear picture of how and when staff are meeting a persons needs. Daily statements are made as to how the service user spent the day and records any specific problem/ concerns encountered. A daily statement recorded the use of a catheter, on checking, a specific plan of care for the use of catheters had not been formulated and there were no instructions for staff to follow to reduce the risk of infection or the action to be taken in the case of an emergency. Another recording in the daily report indicated that the tissue viability nurse had visited to give advice on a particular pressure ulcer, although nurse interventions had been recorded in the daily report, a specific care plan had not been formulated to instruct staff on the type of dressing to be used, the frequency of the dressing change or to record any improvements or deterioration of the wound. Healthcare professionals are contacted when necessary; recordings indicate that the GP, speech and language therapist, tissue viability nurse, dentists and opticians have all visited the home on occasions. During the morning of the inspection a concern was identified by the nurse of the maintenance of a satisfactory blood sugar level. The nurse took swift action in an attempt to rectify the problem. The home operates a twenty eight day regimen for the administration of medication using a monitored dose system with the additional use of bottles and boxes. The Medication Administration Record (MAR) charts record the amount and date of the receipt of the medication. The instructions for any additionally prescribed medications during the month are handwritten out in full on the MAR. A number of oxygen cylinders were being stored in a cupboard on the first floor, none of which had been chained to the wall to prevent them falling over and injuring a member of staff. It was also seen that the home was not displaying a statutory warning notice on a bedroom door where oxygen was being used. This was discussed with the acting manager, it was confirmed that immediate action would be taken to remedy this. Some external preparations (Sudacrem) were not being dated upon opening the manager was advised to introduce this practice and discard tubs after one month of opening and tubes after three months of opening. The care staff were observed to be assisting service users with personal care discreetly and in a manner which promotes service users’ dignity. All service users looked very well groomed, it was obvious that staff are very attentive to ensuring that high standards of personal care are maintained. The statement of purpose has details of the arrangements for dealing with mail on a daily basis. Two service users commented that ‘staff are very good and they look after us well’. All staff spoken with demonstrated a sound, in depth knowledge of all service users and the amount of care each individual needed and preferred. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 12 Lots of chatter, conversations and interactions were observed between the service users and staff during the time of the inspection. All appeared to be very well at ease with each other. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 13 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): OP 12,13,14,15 Quality in this area is excellent. This judgement has been made using available evidence including a visit to this service. The daily living and social activities arranged for service users takes into account the differing expectations, preferences, lifestyle and capacities of each individual. EVIDENCE: Two members of care staff have been allocated the additional duty of arranging social activities, one care staff was busy during the afternoon with assisting service users to make greeting cards. She commented that at times it is difficult to get the participation of service users but nevertheless activities are arranged daily. Two service users spoke with enthusiasm of a recent rock and roll afternoon and stated that they thoroughly enjoyed this music as it ‘brought back loads of lovely memories’. The statement of purpose details the arrangements for the religious denominations and the regular visits from the ministers. Service users confirmed that if they so wish they are able to have communion either as a group or individually. The matron spoke of other faiths and confirmed that if needed arrangements for visits to religious establishments or visits from the clerics would be made. One visitor at the home stated that he could visit the home at times to suit his relative and was welcomed by the staff on each occasion. The statement of Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 14 purpose details the visiting arrangements and if needed an overnight stay may be arranged. Details of the visiting arrangements are displayed at the entrance of the home and in the hall. During the tour of the premises many of the bedrooms were individualised with personal belongings. Staff were observed to be offering choices to service users throughout the day, the choices and options very much dependent on the capacity of the individual. Two service users spoke of their decision to move from the home to a more independent unit, and discussed their stay at the home which they both felt was ‘very good’ but thought that the move it would be beneficial to them both. Staff were very supportive in facilitating their request. Two people are resident at the home whose first language is not English; the manager and care staff discussed the alternative methods of communication with obtaining communication boards, asking family members for significant phrases and obtaining interpreters when necessary. Details of how to access the advocacy services are included in the statement of purpose and displayed on the notice board. The home operates a four weekly rotational menu; service users state ‘ the meals are very good’. The dining room is prepared well in advance, with the menu for the day displayed on each table. One service user stated that staff inform of the menu and the alternatives on offer but couldn’t remember what she had actually ordered but stated that ‘it didn’t matter as all the meals are lovely’. Two service users discussed with the manager some difficulties they had experienced with the supper meal. The manager spent a long time discussing this with them, her previous instruction for the chef to contact them directly and the solutions that had been offered. Staff were observed to be assisting the more frail people with their meal in an unhurried and relaxed manner. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 15 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): OP 16,18 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Concerns or complaints are dealt with promptly and professionally and the arrangement for the protection of vulnerable adults is satisfactory. EVIDENCE: The comments, suggestions and complaints procedure is detailed in the statement of purpose, a copy is displayed on the notice board at the entrance to the home. A copy has also been given to each service user and the manager is endeavouring to ensure that each relative/representative has a copy. The manager demonstrated a sound knowledge of dealing with concerns, complaints and adult protection issues. Two recent complaints were referred to the vulnerable adults multi-agency team for investigation through the protection of vulnerable adults procedures. Both complaints were fully investigated and have been closed following satisfactory explanations. No further concerns/complaints have been made directly to Commission for Social Care Inspection. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 16 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): OP 19,26 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, safe environment in which to live. EVIDENCE: The manager explained the ongoing maintenance and redecoration programme in operation with plans for the corridor carpet on the first floor to be replaced. The bathrooms are currently being refurbished and refitted. Communal areas are well furnished and comfortable. Three service users commented that their bedrooms were ‘very comfortable’. Other service users stated that the home is ‘lovely and peaceful’, ‘lovely gardens’, and that other service users were ‘ good company’. During the tour of the building wooden wedges and some pieces of furniture were being used to keep open doors both in the communal and private areas of the home. Where there is a need or personal preference for fire doors to be kept open then the appropriate door closure, which is linked into the fire alarm system, must be fitted. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 17 The automatic sluice disinfector is not in working order. Observation during the tour indicated that many commodes are in use especially for nighttime purposes as many of the bedrooms are without an ensuite facility. Bedrooms and communal areas have been supplied with hand washing facilities for staff to use at the point of the delivery of care. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 18 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): OP 27,28,29,30 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. There is an established staff group working positively and enthusiastically to provide the residents with a quality of life that meets their individual requirements and aspirations. EVIDENCE: The manager confirmed that staffing levels are maintained in line with the minimum requirements; the rotas are maintained of the staff on duty. Observation during the day demonstrated that staff were extremely busy attending to the individual requirements of service users. Staff commented that in their opinion there were insufficient staff to provide the care that the service users needed and stated that the levels were not based on the dependency requirements of service users. On observation all service users looked extremely well groomed and well nourished it was obvious that all staff work very hard to maintain high levels of personal care. Care staff confirmed that National Vocational Qualification training in care continues to be available. The statement of purpose details the qualifications, skills and quantity of the differing levels of staff. The manager discussed the difficulties with staff recruitment due to the rural location of the home. However recruitment of staff continues, with some potential applicants going through the recruitment procedures. Three staff personnel files were selected for inspection each contained the required documentation for identity checks, references and criminal record bureau disclosures. Each staff member is currently undergoing an annual Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 19 appraisal of their work performance and having their training and development needs identified. Regular formal supervision of staff is ongoing. The manager has introduced a mentorship and induction programme for all newly qualified nurses, one nurse commented that she felt this to be very useful, helpful and informative. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 20 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): OP 31,33,35,38 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The acting manager is service user focused and leads and supports a strong staff team who have been recruited and trained to a high standard. EVIDENCE: Since the last statutory inspection in March 2006, the home has recruited an acting manager, Sue Beddows. Mrs Beddows is a first level nurse with the skills and experience to successfully manage a care home. A formal application with Commission for Social Care Inspection for the position of registered manager at the home is currently being processed. Staff and service users commented and observation of the current leadership style confirmed that the management approach is open and positive with clear lines of communication established. Quality assurance and monitoring systems are continuing. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 21 Senior and care staff meetings are organised monthly. A summary of the answers received following distribution of a service user satisfaction questionnaire has been produced and views of the home from community healthcare professionals has been sought. Clear guidelines for the safe keeping of service users personal monies are detailed in the statement of purpose. The administrator confirmed that no actual cash belonging to any service user is kept on the premises but records are maintained of four people with separate bank accounts, for which the home accepts responsibility, are kept. All transactions are documented, signatures obtained and the balance recorded. Sundry cash expenditure, if required, is paid through the petty cash system and then invoiced to the individual or representative. Documentary evidence is available for promoting and protecting the health, safety and welfare of service users, staff and visitors. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 22 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 3 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(2) Requirement All care plans must be reviewed at least monthly or more frequently if a change in need has been identified. The incidence of pressure ulcers, their treatment and outcome must be recorded in the service users care plan and reviewed on a continuing basis. Wooden wedges or pieces of furniture must not be used for keeping communal or private area doors open Automatic sluice disinfectors must be available and in good working order Timescale for action 15/09/06 2 OP8 17(1)(a) Schedule 3(p) 23(4) 15/09/06 3 OP19 31/08/06 4 OP26 13(3) 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is recommended that all external preparations are dated DS0000061781.V297462.R01.S.doc Version 5.2 Page 24 Woodcote Hall upon opening and discard tubs after one month of opening and tubes after 3 months of opening. Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Woodcote Hall DS0000061781.V297462.R01.S.doc Version 5.2 Page 26 - 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. 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