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Inspection on 26/09/05 for Woodcross Mental Nursing Home (Highfields)

Also see our care home review for Woodcross Mental Nursing Home (Highfields) for more information

This inspection was carried out on 26th September 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is very well presented to prospective clients both in general appearance and in the excellent sources of information provided to enable prospective service users to decide if the home will suit them. Arrangements for pre-admission visits and trial periods are seen by service users and staff as very helpful to settling in to the home. The home has very good assessment procedures and care planning systems in place and service users are confident that their personal needs are understood and can be met. The staff are seen to have excellent relationships with the residents interacting naturally, with empathy and deliver care as the person wishes, achieving a high level of satisfaction and sense of wellbeing amongst the residents. The home gives a high priority to obtaining service users views and demonstrate a commitment and flexibility in adapting services to address wishes where there is consensus.

What has improved since the last inspection?

The home have identified an advocacy service that is able to support younger adults and information of its services are given prominence. The service user guide has been made available in all bedrooms and all new service users are given written confirmation that the home can meet the agreed needs before entering the home. All bedroom doors that have observation windows have curtains to obscure them to promote privacy.

What the care home could do better:

The home should keep the statement of purpose up to date and inform the Commission of any changes.

CARE HOME ADULTS 18-65 Woodcross Mental Nursing Home (Highfields) Woodcross Mental Nursing Home 23 Reeves Street Bloxwich Walsall West Midlands WS3 2DG Lead Inspector Richard Eaves Unannounced Inspection 26th September 2005 09:30 Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 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 Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.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 Adults 18-65. 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. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodcross Mental Nursing Home (Highfields) Address 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) Woodcross Mental Nursing Home 23 Reeves Street Bloxwich Walsall West Midlands WS3 2DG 01922 497394 01922 497395 Southern Cross Healthcare Centres Limited Sophia Nuala Fletcher Care Home 44 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (44), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (44) Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 42 Mentally Ill adults from the age of 18 years. 1 named resident on Section 42 of the Mental Health Act restriction. 3 of whom may be on Section 7 of the Mental Health Act 1983 (Guardianship Order) 24th January 2005 Date of last inspection Brief Description of the Service: Woodcross Nursing Home is registered for adults with enduring mental ill health. It is a purpose built two storey building owned by Southern Cross Healthcare Centres Limited. The home is located near the centre of Bloxwich with local bus services, shops and other amenities close by. The home recently completed a programme of refurbishment and decoration and is furnished to a high standard. A number of double bedrooms have been altered to single occupancy rooms, which has resulted in a reduction in the number of places available. The home is well managed and the staff team work hard to maintain a therapeutic, rehabilitative approach to care. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.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 undertaken by one inspector over one day. The focus of the inspection was on the delivery of care and included case tracking. The inspector had opportunity to speak with most service users and those willing to communicate were positive regarding all aspects of the home and care provided and they were happy to confirm that they were content with life at the home, there was a relaxed atmosphere among service users and staff. The inspection also included a tour of the building, meeting with service users and inspection of records. What the service does well: What has improved since the last inspection? The home have identified an advocacy service that is able to support younger adults and information of its services are given prominence. The service user guide has been made available in all bedrooms and all new service users are given written confirmation that the home can meet the agreed needs before entering the home. All bedroom doors that have observation windows have curtains to obscure them to promote privacy. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 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. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The homes statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home, this is confirmed at admission by contract. Skilled and experienced staff use a comprehensive range of assessment tools, which means that service users needs are thoroughly assessed to ensure that care needs will be met and confirmation of this is given. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions that are right for them. EVIDENCE: The Statement of Purpose and Service users Guide have been subject to review since the change of ownership and are useful, informative and have been reissued to each service user. A further company title has been made and this minor alteration requires to be shown in these documents. The homes senior staff undertake extensive pre-admission client enquiry/assessments of prospective service users using a research based assessment tool including in depth mental health assessments and confirmation that the home will be suitable to meet the assessed needs is provide prior to admission. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 9 Pre-admission visits, including overnight stays are considered essential in establishing the suitability of the prospective service user for the home and acceptance by other service users. In addition to the Care Management Assessment/Care Plan the home undertakes its own needs assessment and covering items identified in standard 2.3 for adults and standard 3.3 for older persons. A range of risk assessments are also undertaken as required by the standards and on an individual needs basis such as smoking and going out alone. All assessments are subject to regular reviews. A contract and a document of terms and conditions for the placement at the home is provided at the time of admission. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 – 10 Care planning at the home is good, clear and consistent, providing staff with the necessary directions of actions required, to ensure that service users care needs are fully met and health is promoted. Service users are fully involved in all aspects of life at the home and are supported to make decisions for themselves and encouraged to be as independent as possible, even though this may mean taking risks. Service users are frequently consulted and encouraged to be involved in all aspects of life in the home. Service users can be confident that information given about them will be dealt with confidentially and in their best interest. EVIDENCE: A sample of case files were inspected and found to contain an individualised plan of care developed from the extensive range of assessments, which covers all aspects of personal and social support, mental and physical healthcare needs. The plan is drawn up with the involvement of the service user as appropriate. The files demonstrate that service users are supported in Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 11 decision-making regarding their lives. The plan of care details any agreed restrictions on freedom and choice as a result of risk assessments and is kept under review. Service users are encouraged to participate in the monthly meetings and other more frequent ad-hoc meetings to discuss issues pertinent to the home such as meals, activities and smoking. Regular user satisfaction questionnaires are also undertaken. Comprehensive risk assessments are conducted prior to and on admission to the home. Risk management strategies are devised with the involvement of the service user and recorded in the individual plan. A procedure is available for staff to follow should service users go absent. The home has a detailed confidentiality policy and staff receive training at induction and kept high on the managers agenda for ongoing staff updates. Service users files are kept secure and were clear, factual and appropriate on the day of inspection. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 – 17 Staff support service users to access opportunities for their personal development and health promotion. Service users are enabled to get out and about in the local community and the nearby town and take responsibility for their participation in the life of the wider community. The involvement of family and friends is encouraged in agreement with the service users wishes. The home provides a varied social and recreational activity programme that provides interest and pleasure for service users. Meals at the home are wholesome and meet the nutritional needs of service users while providing for choice and personal taste. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 13 EVIDENCE: Eight service users are currently enrolled on college education courses and a further attends ‘Links to work’, while another works part time in a local café. While the activities co-ordinators lead in providing practical life skills training. Support is given to enable service users to make use of services, facilities and activities available in the local community; this is a recognised part of staff duties. The process of attending these activities also forms part of the service users therapeutic programme. The activities programme includes a range of activities within and outside of the home, these include attendance at a fitness group, gardening and swimming. The home has access to its own transport; local public transport is easily accessible. A number of service users have been away for holidays this year while most participate in excursions. The home has recently gained regular access to a caravan and this is expected to increase the opportunities for holidays to be taken. Individual choice is promoted as far as possible for this particular client group and staff were seen to interact with service users with respect and kindness. The observation panels in bedrooms doors have been obscured with curtains to promote privacy. Subject to individual assessment service users have a key to their bedroom and access the front door via a coded key-pad, many service users were observed to come and go freely. There is a four-week rotational menu in operation, which includes choice at the three main meals; supper is included on the menu. Lunch was served during the inspection and the meal appeared appetising, tasty and nutritious and was enjoyed by all. Past surveys of satisfaction have shown a good deal of satisfaction with the meals. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 Healthcare needs are well documented and are compiled with the input of the individual service user. The care plans give clear directions to ensure that service users’ healthcare needs are assessed, recognised and addressed. Arrangements for the administration of medication are good and ensure service users medication needs will be safely met. EVIDENCE: Every shift is led by a psychiatric nurse to meet the day to day mental health nursing needs and each service user has allocated a key worker to provide consistency of approach to meeting the individuals wishes in respect of maintaining their routines and choices. Service users mental and physical health is monitored closely and the home is supported in providing mental health care by the support of the local psychiatric team to monitor and review service users needs and progress. Arrangements for the receipt, recording, storage, administration and disposal of medicines comply with the homes policy and this standard and action has been undertaken to implement the new pharmaceutical waste requirements. No service users are currently assessed as able to self administer or control their own medications. The manager confirmed that service users are all subject to regular medical review of their medication regimen. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes to an environment that is safe from abuse. EVIDENCE: The concerns/complaints policy and procedure has been kept under review and no complaints have been received during the preceding year. The home has policies in keeping with national guidance and staff receive training in adult protection procedures provided by Social Services. The home has recently made available details of a new advocacy service ‘Care Aware’ which will offer an independent source of support for service users. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The home provides a good standard of décor, furnishings and managed services providing a safe environment and a comfortable, attractive, and homely place to live. The home is clean and hygienic and free from odours. EVIDENCE: The home is located near the town centre of Bloxwich, local bus services, shops and other amenities are close by. A programme of refurbishment of the whole premises has recently been completed and the home is decorated and furnished to a high standard. The premises were seen to be safe, comfortable, clean and hygienic and free from odour on the day of inspection. A maintenance programme is in place with records of regular monitoring and servicing. The laundry has suitable procedures in place for dealing with soiled linen and washing machines have appropriate programmes for sluicing and disinfection. Laundry and domestic staff are employed in sufficient numbers to ensure standards related to hygiene are met. A sluice disinfector is available on the ground floor and has been fitted with a smoke detector since the previous inspection. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 33 & 36 Staff are enthusiastic, sufficient in numbers, well trained, supportive and committed to maximising the service users quality of life. The recruitment practices, staff training and supervision all contribute to ensuring service users benefit from the skills and knowledge of the staff. EVIDENCE: A sample of staff files were viewed and show that recruitment procedures are completed to a good standard with appropriate checks in place. Job descriptions appeared satisfactory for roles and support the underlying values of the home. Nursing and care staff collectively have the skills and knowledge to meet service user needs and are rostered in sufficient numbers both during the day and at night. Normal staffing levels are for 2 RMN, 4 carers and 2 activity coordinators during the day and a nurse and 3 carers overnight. This number is occasionally increased during the evening to accommodate service user activities. Supervision is well established and records are kept of individual sessions and group supervision/reflective practice sessions. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. EVIDENCE: The manager is a registered nurse with a management qualification and has recently updated this by undertaking the Registered Managers Award. The manager is well regarded and liked by the service users and staff alike. A full range of servicing, maintenance and regular monitoring of services and equipment is undertaken and staff receive training in health and safety and first aid. Records of all accidents are recorded, using data protection compliant documentation and reported as necessary, an audit of all accidents is undertaken on a quarterly basis. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 19 Induction and foundation training is provided to TOPSS requirements. Overall the premises were observed to be managed to meet safety requirements. Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X 3 X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The registered person must keep the statement of purpose and service user guide under review and notify the Commission of changes. Timescale for action 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Woodcross Mental Nursing Home (Highfields) DS0000039550.V251831.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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