Inspection on 04/10/05 for Woodcote Hall

This inspection was carried out on 4th October 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

Woodcote Hall 11/11/09

Woodcote Hall 27/01/09

Woodcote Hall 08/05/08

Woodcote Hall 18/04/07

Woodcote Hall 16/08/06

Woodcote Hall 01/03/06

Woodcote Hall 30/03/05

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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 Lorraine Briggs Announced Inspection 4th October 2005 09:30 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.V255150.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. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 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 Shelagh Newman 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.V255150.R01.S.doc Version 5.0 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 22.00-08.00 2 RGNs 2 RGNs RGN 6 Care Assistants 6 Care Assistants Assistants One named resident as per discussion of 13.09.05 1 5 Care 4. Date of last inspection 30th March 2005 Brief Description of the Service: Woodcote Hall is a large, converted, country house registered to provide care for 56 older people, including up-to 28 places for the provision of ‘Nursing Care’. The Home is set within it’s own grounds and sited directly off the A41, south of the town of Newport. It is owned by Select Healthcare Ltd., with the Responsible Person being Mr. Roy Bernard and the ‘Registered Manager’, Ms. Shelagh Newman. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and commenced at 9.30am. Two Inspectors undertook the visit which included observing activity within the home, inspecting the premises, looking at records and case tracking and talking to 14 staff and 16 residents. The Manager and staff on duty were welcoming and helpful throughout the inspection. It was found that all of the National Minimum Standards assessed had been met, with plans firmly in place to continue improvement, in particular relating to environmental factors. It was considered that the overall quality of care provided was good. All residents appeared happy, content and very well cared for and those who were able expressed complete satisfaction with their quality of life at the home. What the service does well: What has improved since the last inspection? The improvements identified at the time of the last inspection continue to be implemented. Admissions to the home continue to be well managed with all prospective residents being visited prior to moving in the home. Staff communication has been improved with the introduction of a communication book. Care and nursing staff are allocated to particular residents in their care, this is recorded. Care staff produce a daily report sheet. The Manager of the home has arranged a talk for all staff from a representative of the Royal College of Nursing on issues regarding accountability. Care documentation has been reviewed and the wound risk assessments and nutritional assessments have been reviewed. A monthly newsletter is produced. Refurbishment and redecoration of the following: foyer, main hall, all downstairs corridors, small dining room, nursing landing annex, residents smoking area, 19 bedrooms, pantry 1 & 2 redecorated with new laminated shelving and replacement flooring, treatment room – new flooring, nursing bathroom – new flooring. Replacement curtains in two bedrooms and nurses office. New carpet has been fitted to 6 bedrooms, the downstairs corridors and lift area. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 6 The ‘cottage’ has been completely refurbished to provide accommodation for overseas staff. The following equipment has been purchased: Replacement bed linen, curtain and towels. Main hall furniture re upholstered. Sluice washing machine. 3 vacuum cleaners and a carpet cleaner. 3 vanity units and 2 WC’s. 2 convector heaters fitted in large sitting room. 2 hospital beds. Extractor fan for residents smoking room. 2 serving trolleys. Various mirrors, chandeliers, wall cabinet, round table for hall and 2 coffee tables. 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.V255150.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 Woodcote Hall DS0000061781.V255150.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): 1, 2, 3, 4 and 5 Service users are assessed before moving into the home. Relatives are provided with the opportunity to visit the home to assess its quality, facilities and ability to meet an individual’s needs prior to admission. Staff in post continue to provide the type, and quality, of care required by Residents. EVIDENCE: A ‘Statement of Purpose’ and ‘Service User Guide’ are available in the Home, which incorporate the ‘aims’ of the Home and Complaints Procedure. The Statement was last updated in August 2005. The information is made available to all Service Users/Relatives, and appears comprehensive, clear and easy to read it was seen on display during the inspection. Service Users are admitted to the Home only after a full ‘needs assessment’ has been carried out. This is undertaken by the Home Manager/Matron or, in her absence, by her designated deputy. The assessment process involves the application of three documents – a ‘Pre-Admission Assessment Sheet’; a ‘Life History Sheet’; and a ‘Social Survey Sheet’. When used in conjunction these forms address all the elements listed in the Standard. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 9 Staff in post possess the formal training and experience necessary to meet the range of needs presented by the client group, which includes persons designated ‘elderly frail’, ‘elderly mentally ill’ and ‘residential’. The Staff group comprises - Registered General Nurses, a Registered Mental Nurse and Care Assistants with various levels of National Vocational Training attainment. The Home’s Manager has many years experience in the care home sector, much of it obtained in Shropshire and the neighbouring Counties. Prospective Service Users are offered the opportunity to experience the services provided at Woodcote Hall by way of day attendance, an overnight stay or week long stays of ‘respite’ placement. At this time they are offered a range of ways in which to gain an understanding as to whether the Home would be suitable for them, and, indeed, for the Home to determine it’s ability to meet the individual Service Users’ assessed needs. The Terms and Conditions of Residency document, which is given to the Service User on admission, clearly sets out the right of the Service User, or the Home, to terminate the arrangement. This usually involves review meetings at two weeks and four weeks after admission. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The health and personal needs of residents appear to be well met with evidence of regular review and of good multi disciplinary working taking place on a regular basis. EVIDENCE: It was evident during the inspection from looking at records, inspecting the facilities and chatting to staff, visitors and residents that individual health, personal and social care needs were being met. Staff who were spoken to during the inspection were extremely knowledgeable regarding the residents in their care. Residents were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. During the inspection seven very frail residents were seen to be being nursed in bed. All of these residents appeared to be being very well cared for, they looked clean and comfortable. One resident who is too frail to get out of bed has had her bed positioned in a way in which she can see the adjacent garden containing some of her own furniture via a mirror. Care staff and Nurses work together to deliver the care. An allocation sheet has recently been introduced as have allocation sheets and a carers daily report. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 11 The care plans for four residents were reviewed during the inspection, documentation included the Care Plan and additional operational documents covering a range of areas, including nutritional/body weight issues, pressure sore occurrence, the need for bed safety rails, continence management and risk assessment to determine the probability of falls. All of these documents have been integrated well into the care process. Securing, administration and the recording of medication appeared satisfactory. The home has implemented measures to address the new guidelines regarding the disposal of medicines. Care and assessment regarding the prevention of development of pressure ulcers is good. One resident is actively being treated for pressure ulcers at this time. The care plan for this resident was reviewed, photographs had not been taken at the request of the resident. The home has established close links with the District Nurses and Tissue Viability Nurse. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The routines of daily living at Woodcote Hall are flexible and each resident finds the lifestyle experienced in the home meets their individual needs. Many activities take place, there is an open visiting policy and the menu offers a choice of well balanced and wholesome meals. EVIDENCE: The residents are encouraged and enabled to personalise their bedrooms, this was observed on the tour conducted of the home, a total of 25 bedrooms were seen. The residents reported that they enjoy good meals in the pleasant dining areas or in their own rooms. A recent residents meeting that was held on 27th September focused on the menus. The meeting was held in small facilitated groups, this being a suggestion of the residents as a previous large meeting held in a dining room had posed difficulties for residents with hearing difficulties. The newly appointed cook read through the menu and explained what each meal was, including all the ingredients used, how the meal was prepared and cooked, vegetarian and specialist diet options were also discussed. The residents were given the opportunity to comment and make suggestions. Following the implementation of the new menu it was suggested by the staff that comment slips would be available every day and a meeting would be held in a weeks time. In general comments were very positive, some being ‘We always get good food and plenty of it, no one goes hungry.’ Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 13 ‘Yes I will be happy to try the new meals and let you know.’ One gentlemen commented that he did not get ice cream with his dessert, the management stated that they would search for a supplier of sugar free ice cream. There are a number of activities arranged for residents within the home and outside. A monthly newsletter is freely available throughout the home, it lists forthcoming events for example entertainers visiting, trips arranged, hairdresser visits or clergy visits. The newsletter additionally welcomes new residents to the home and celebrates birthdays and achievements of staff qualifications. Visitors are welcomed within the Home, without prior arrangement, between 0900 and 2100, and outside these times by arrangement. During the Inspection Visitors were observed being made welcome by Staff, and Residents are able to receive their Visitors in private. The Home has clearly maintained links with the local community in Newport and Residents, who are able, are assisted in visiting the Town’s shops and pubs. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Concerns and complaints are dealt with promptly and professionally and robust procedures and practices are in place to ensure that individuals are protected from abuse. EVIDENCE: The Complaints Procedure incorporates stages, and timescales, for the complaints management process, including referral of a complaint to the CSCI. A record is kept of all complaints. There appears clear commitment to ensuring all complaints, and concerns, received in the future will be recorded and professionally dealt with. Staff Records demonstrated that training in relation to the application of the Home’s Complaints Policy and Procedure is included as part of documented induction, and continues in on-going training. Written policies are available regarding the need to safeguard Service Users from abuse, and information relating to Local Authority Protection of Vulnerable Adult Procedures are also available. It was evident from Staff Files, randomly sampled, that Staff have read and understood these policies. A number of staff have undertaken training in adult protection. Risk assessment documentation, relating to the need for individual Service Users to be protected by the implementation of bedrails, and, where necessary, the need for restraint, are maintained within care plans. Woodcote Hall DS0000061781.V255150.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): 19, 20, 21, 22, 23, 24, 25 and 26 The standard of the environment within the home is good, providing residents with a warm, safe and homely place to live. EVIDENCE: The location and layout of the home are suitable for elderly residents. Communal rooms are well equipped and are warm, homely and welcoming. Many improvements have been made to the lounge and dining areas. A full list of refurbishment and redecoration are included in the summary of improvements at the front of this report. Bedrooms are personalised and suit individual needs and the gardens and grounds are attractive and well maintained. Further plans have been identified by the management team, these include continued refurbishment of bathrooms and communal areas and external maintenance. It was identified that a second cooker and grill need to be supplied for the kitchen. It was evident that the Management team, and all staff have worked very hard to improve the environment and are committed to further improvements. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 16 At the time of this inspection the standard of hygiene and cleanliness was excellent Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Residents appear to be supported by a well trained and committed staff group who are meeting the needs of each individual in a sensitive and professional manner. EVIDENCE: Four staff files were seen as part of the inspection process. The files demonstrated that recruitment at the home is thorough and all elements required by Schedule 2 of the Care Home Regulations are maintained on file. The management continue to support staff to undertake their NVQ awards, a good variety of other training has been undertaken and staff on duty indicated that they were very sensitive to the service users needs and disabilities and that their attitudes and practice were monitored and supervised by the Manager and Deputy Manager. A number of outside agencies contribute to the training process, including input from Walford and North Shropshire College, Recorded staff supervision, senior staff meetings, care staff meetings and appraisals are undertaken. The home continues to actively seek recruitment of additional laundry and domestic staff. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 18 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, 34, 35, 36, 27 and 38 There are clear lines of accountability within the homes management structure and the management approach creates an open and positive atmosphere from which the residents benefit. EVIDENCE: It is evident from the main body of this report that the present management structure is effective. All the improvements that have been noted are as a direct impact of the management team. The structure of the home, décor, atmosphere, committed staff team, individualised care, key worker system, communication and staffing levels have all improved meaning that the overall quality of care is good. The Manager and her team all communicated a sense of motivation and commitment to further drive standards at the home forward. Quality assurance systems are in place and there was evidence available to indicate the manager ensures, so far as is reasonably practical, the health, Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 19 safety and welfare of service users and staff. All staff have attended a health and safety and relevant training At the time of this inspection no potential hazards were identified and records required are maintained. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 20 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 32 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 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 4 3 3 3 3 3 3 Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 21 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. 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 2 3 Refer to Standard OP19 OP20 OP27 Good Practice Recommendations The Home completes the agreed plan for repair/refurbishment of bedrooms, public rooms, or other areas yet to benefit from such work. The Home completes the refurbishment /replacement of worn items of furniture. That active recruitment of additional domestic / laundry staff continues until the posts are filled. Woodcote Hall DS0000061781.V255150.R01.S.doc Version 5.0 Page 22 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.V255150.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. 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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