Inspection on 23/01/07 for Woodcroft

This inspection was carried out on 23rd January 2007.

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

Woodcroft 01/02/06

Woodcroft 26/07/05

Woodcroft 30/03/05

Woodcroft 30/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Woodcroft Croft Way Market Drayton Shropshire TF9 3UB Lead Inspector Pat Scott Key Unannounced Inspection 23rd January 2007 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 Woodcroft DS0000020707.V325007.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. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodcroft Address Croft Way Market Drayton Shropshire TF9 3UB 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) 01630 657486 01630 658139 www.coveragecareservices.co.uk Coverage Care Services Ltd Mrs Patricia Ann Cadman Care Home 50 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (30) of places Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may admit one (1) service user below the age of 65 years. Date of last inspection 1st February 2006 Brief Description of the Service: Woodcroft is a purpose built home, situated in a newly built residential area within the town of Market Drayton. It provides residential care for 50 older people, 20 of those with dementia related illnesses. The home presents itself as a large modern open plan building with large well maintained gardens and which has been decorated to a high standard without detracting from the practicalities of providing specialist equipment, wide door ways etc. In addition to the above, the home also has a day care facility for people living in the local community and offers a hot meal delivery service to older people living in the local community. There are five separate units within the home, each offering accommodation for up to ten people. All service users have single bedrooms. Coverage Care Services Ltd make their services known to prospective service users in: The Statement of Purpose, Company Brochure and web site which also contain their contact e mail address. The inspection report is mentioned in the statement of purpose and summarised in the service user guide. It is also on display in all homes’ entrance halls with a note stating the document can be made available to copy and take away. Coverage Care Services rates are reviewed annually on 1st April each year and service users are notified one month in advance. The only additional charges to service users are for toiletries, hairdressing, newspapers and escorting to hospital for routine appointments. This is clearly laid out in the terms and conditions. Fees for Woodcroft are currently: £394.45 All service users pay monthly by standing order or by cheque usually on the 15th of the month. This is two weeks in advance and two weeks in arrears. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, staff records kept in the home, medication records, discussion with people who use the service, discussions with the staff team, discussion with the acting manager, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports, observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? What they could do better: The service provider sets its own objectives for continual improvement which the CSCI are confident the service will meet. The key National Minimum Standards under the outcome headings are generally met or exceeded but there are some areas of improvement relating to staff management that the CSCI are confident the provider can manage. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Woodcroft DS0000020707.V325007.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 Woodcroft DS0000020707.V325007.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standard 3. Key Standard 6 is not applicable to this service. National Minimum Standards 1.2. Prospective service users and their representatives have the information needed to choose a home which will meet their needs They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: Prospective service users are given the opportunity to have a trial period of time in the home. An individual member of staff (keyworker)is allocated to give them information and to help them to feel comfortable in their surroundings. A service user commented that they had been able to ask any questions about life in the home. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 9 Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. Records show that the staff team are qualified and experienced to work with the needs of the service users. Documentation and training logs also show that specialist areas of work have been explored and that staff have access to detailed guidance and training materials. The home provides a statement of purpose (SOP) that clearly sets out the objectives and philosophy of the service supported by a service user guide that summarises the SOP and provides good clear information about the home. The guide is precise in what the prospective service user can expect and gives a good detailed account of the quality of the accommodation, qualifications and experience of staff, how to make a complaint, recent CSCI inspection findings and contains comments and experiences of service users living at the home. All service users have a copy in their room. The service can provide a copy of the SOP and guide in a format which will meet the capacity of the service user when requested. Each service user is provided with a statement of terms and conditions prior to moving to the home, examples of which were seen. This sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the service user. This is clear, jargon free, easy to understand and gives the service user a very clear understanding of what they can expect. Admissions are made to the home after a full needs assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. For people whom are self funding and without a care management assessment the assessment is always undertaken by a skilled and experienced member of staff. Evidence seen in care files confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the service user. Where the assessment has been undertaken through care management arrangements the registered person insists on receiving a summary of the assessment and a copy of the plan. Woodcroft DS0000020707.V325007.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 7.8.9.10 The health and personal care, which a service user receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The service believes in the service users’ right to be involved in the planning of care as it affects their lifestyle and quality of life. Each service user has an initial plan that has been agreed with them and where appropriate signed by them or their immediate family. This is written in plain language, is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. The plan also includes a risk assessment element. Services users admitted for Dementia care have a specific risk assessment in place. Staff have the skills and ability to support and encourage service users to be involved in the ongoing development of their plan. Key workers are appointed who build up special relationships with service users Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 11 and work on a one to one basis. The home ensures that each service users plan is reviewed regularly and involves the service user and where agreed their family. The plan is updated and the necessary action taken to respond to any changes. Members of staff spoken with regard the plan as a working tool. They understand the plan and were fully conversant with its content. Service users have right of access to health and remedial services and the home’s policies, procedures and practice guidance strongly support this. The health care needs of those service users too frail to leave the home are managed by visits from local health care services e.g. the district nurse was visiting service users on the day of inspection. Service users’ personal aids are well maintained and the home provides the necessary aids and equipment to support both staff and service users in daily living. Service users have individual health care plans that give a comprehensive overview of their general health and acts as an indicator to changing health needs. Service users have the choice to shower or bath when they wish, and are supported and facilitated to be independent in their personal hygiene. A medication round observed on one unit showed that medication is signed for before administration which does not comply with the policies and procedures for the home. The aims and objectives of the home reinforce the importance of treating service users with respect and dignity and these values were seen and heard. Particular attention is given to ensuring privacy and dignity when delivering personal care. Doors were closed after entering bedrooms. Induction training covers privacy and dignity. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Key Standards 12.13.14.15 Service users are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Service users receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: Rotas showed that sufficient staff resources are provided to allow time for activities and stimulation. The home operates a key worker system, which enables closer service user/family staff relationships where likes, dislikes and needs are shared. The home has developed a system for displaying information and bringing attention to community events and activities. The home has an activities coordinator who is responsible for creating meaningful activities and experiences both in the home and the wider community. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 13 Service users stated that family and friends are made welcome and know they can visit the home at any time. Staff were seen to make time to talk to service users, particularly one person who was in an agitated state. The design of the home provides seating areas within the communal areas of the home where service users can entertain their visitors, in addition to the privacy of their own room. Staff support those service users who need help in financial matters, they work to a clear company policies that protects the service user from financial abuse and clearly directs staff in their practice. The home is able to offer service users information and telephone numbers for contacting independent people who will act as advocates on the service users’ behalf where the service user prefers the help of an independent person. Service users have the choice to bring a limited amount of small goods with them on admission to the home and were seen to keep personal items which are important to them in their own room. An experienced cook is responsible for providing quality nutritional meals that meet the dietary needs of the service users. The cook is familiar with the dietary requirements recorded in the service users care plan and provides a diet that meets their individual needs. They hold the gold award for healthy eating. Tables were set attractively for breakfast with the necessary cutlery and aids to help individuals during their meal. Regular drinks are available and staff were seen to make a cup of tea at any time when asked. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 16.18 Service users have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. EVIDENCE: The service has a complaints procedure that is up to date, clearly written, and is easy to understand. Service users, when asked, were clear that they could speak to staff about any concerns they may have. The complaints log recorded two complaints from one family which were dealt with by the home and according to procedure. However, the outcome could have linked in more robustly with the service’s disciplinary procedure. The policies and procedures regarding protection of service users are in place. Training of staff in the area of protection is regularly arranged by the home. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. Service users stated that they are very satisfied with the service provision, feel very safe and well supported by staff. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 19.26 The physical design and layout of the home enables service users to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the service users. They have the choice to bring small personal items of furniture into the home as was seen in those rooms entered. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 16 The service conducts its own reviews of the premises and records any action taken to remedy defects. The service is without a maintenance person at present and staff are fulfilling some duties such as fire records, hot water checks. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Key Standards 27.28.29.30 Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of service users. EVIDENCE: Services users commented that staff look after them well and were very kind. Management encourage staff members to undertake external qualifications beyond the basic requirements, and recognise the benefits of a skilled, trained workforce. The service clearly defines the roles and responsibilities of staff through accurate job descriptions and specifications. The service ensures that all staff within its organisation receive relevant training that is focussed on improving outcomes for residents. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. An induction file and training portfolio of a member of staff was seen and a training portfolio of another member of staff. Both verified the training provided as per conversations. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice as seen from the recruitment records of a new staff member. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 18 This person confirmed that the service was clear about what was involved at all stages and was robust in the following of its procedure. NVQ training is high priority with over 75 of care staff having level 2. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 31.33.35.38 The management and administration of the home is based on openness and respect and has effective quality assurance systems developed by the provider. The management arrangements in place, in the absence of the registered manager, have ensured continuity in the performance of the home. EVIDENCE: An acting manager is in place to cover the absence of the registered manager. The home has policies and procedures, which the provider effectively reviews and updates, in line with current thinking and practice. Systems are in place to monitor staff adherence to policies and procedures during their practice. However, the result of a complaint investigation regarding staff practice Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 20 following an accident, should have linked more formally into the home’s disciplinary process. Management processes ensured that staff received feedback on their failures through supervision but the manager stated this had not been formally recorded. The provider has a good record of meeting relevant health and safety requirements and legislation and conducts its own audit to ensure compliance with policies. Records are of a good standard and are routinely completed. Fire records were sampled and were in order. Business planning provides a quality assurance and monitoring process through service users satisfaction questionnaires and service user meetings. The home has all the necessary insurance cover in place to enable it to fulfil any loss or legal liabilities. If they wish and are able to, service users are helped to take responsibility for managing their own money. They are provided with facilities to keep their valuables and money safe. Where the home is responsible for service user’s money it works to a very rigorous system, it maintains very clear records that are routinely kept up to date and can be used to track individual residents finances. These arrangements are regularly audited by management. The key National Minimum Standards under this outcome heading are generally met but there are some areas of improvement that the CSCI are confident the provider can manage. Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 21 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 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 Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Woodcroft DS0000020707.V325007.R01.S.doc Version 5.2 Page 24 - 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!