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Inspection on 06/03/06 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 6th March 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 found no outstanding requirements from the previous inspection report, but made 5 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. The home provides very person centred personal care in a friendly, homely atmosphere and a very pleasantly maintained environment. The assessment of needs process and the derived care plans are thoroughly maintained and of a good standard. 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.

What has improved since the last inspection?

The service user guide and statement of purpose have been reviewed and the up dated version issued to service users.

What the care home could do better:

The home is currently without a manager and this has resulted in the acting arrangements having to limit the amount of supervisions they have been able to offer care staff, it has also resulted in no formal surveys of service user views being undertaken. The number of staff holding an NVQ qualification has been eroded by staff leaving with no enrolment of new staff on the course to meet the shortfall. An activities co-ordinator has left and a second is leaving restricting the level of organised social and leisure activities provided.Over the winter period a number of double glazing units have failed and this detracts from the view and the efficiency and in the same area the wallpaper is peeling away.

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 6th March 2006 09:30 Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 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.V283363.R01.S.doc Version 5.1 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.V283363.R01.S.doc Version 5.1 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.V283363.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 42 Mentally Ill adults from the age of 18 years. 3 of whom may be on Section 7 of the Mental Health Act 1983 (Guardianship Order) 1 named resident on Section 42 of the Mental Health Act restriction. Date of last inspection 26th September 2005 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.V283363.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced 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 many of the service users and those able to communicate were positive regarding life at the home and they all appeared content. 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? What they could do better: The home is currently without a manager and this has resulted in the acting arrangements having to limit the amount of supervisions they have been able to offer care staff, it has also resulted in no formal surveys of service user views being undertaken. The number of staff holding an NVQ qualification has been eroded by staff leaving with no enrolment of new staff on the course to meet the shortfall. An activities co-ordinator has left and a second is leaving restricting the level of organised social and leisure activities provided. Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 6 Over the winter period a number of double glazing units have failed and this detracts from the view and the efficiency and in the same area the wallpaper is peeling away. 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.V283363.R01.S.doc Version 5.1 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.V283363.R01.S.doc Version 5.1 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. 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. A sample of residents files were inspected and show the assessment process to be thorough, including all activities of daily living and an extensive range of risk assessments, all assessments are subject Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 9 to monthly review. The file documents information of the service user or representatives involvement in the assessment process. 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. Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 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. This is supported by a procedure for dealing with unexplained absences. The best interests of service users are safeguarded and they can be confident that information about them will be maintained securely. EVIDENCE: A sample of case files were inspected and found to contain care plans that were drawn up to address assessed issues and problems and these were kept under frequent review. The inspector found the language used in the documents to be user friendly with plenty of evidence of service user involvement in all aspects of assessment, care planning and reviews. The plan Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 11 of care details any agreed restrictions on freedom and choice as a result of risk assessments and is kept under review. Monitoring charts identified in the care plans were available as were records of GP and Consultant visits. The case files while being up to date also appear accurate and are kept secure and confidential. 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. Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 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.V283363.R01.S.doc Version 5.1 Page 13 EVIDENCE: Service users are encouraged and assisted to take opportunities for personal development although due to the mental health experiences of service users, some do not wish or have the inclination for further learning or therapies. Eight service users attended college last year and completed courses, one continues to attend at this time. The activities programme has become restricted in recent months due to one activities co-ordinator having left and the second about to leave. While the home has its own transport few trips have been arranged but this is usual during the winter period. 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. The lunch served of sausage and mash was very well received by most service users with just a few selecting the alternative. Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 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): 18 – 21 Service users are assisted to maximise their independence and control over their lives and staff respect their privacy and dignity and give support to achieve this. 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. Staff have been developed to provide care at the time of service users dying with sensitivity and respect. EVIDENCE: The home routines are flexible although service users are encouraged to accommodate meal times and medication regimes within their personal routines they are generally encouraged to make independent choices. 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 Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 15 of approach to meeting the individuals wishes in respect of maintaining their routines and choices. 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. Given the nature of the home staff have little practical experience of service users dying at the home but staff receive a limited programme of training included in the NVQ units and the Nursing staff have experience in care of the dying. Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 16 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. Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 17 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, disabled accessible environment and an attractive and homely place to live. The bedrooms have bathrooms in close proximity for the convenience of service users. The home is clean, free from odours and is hygienic. EVIDENCE: A tour of the building found the home to be clean, hygienic and free from offensive odours. Decoration is for the most part with the dining room in most need of attention, two windows in the dining room were observed to have failed double glazing units. The bedrooms and communal areas are comfortably furnished to provide a homely environment. Records are kept which detail routine maintenance and redecoration, the records of monitoring services such as fire, emergency lighting and water temperatures were up to date and show any actions taken if adjustments have been required. The small laundry is well equipped with washers that meet the requirements for sluicing and disinfection of linen. A sluice disinfector is provided for Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 18 cleansing of toileting items such as bedpans and urinals. Staff hand wash facilities, in the treatment room and laundry must have controlled hot water to promote good hand washing practice, the sluice room has no hand wash facility, this should be provided if practical and in the interim alcohol hand rub issued. Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 19 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 - 36 Staff are enthusiastic, sufficient in numbers, supportive and committed to maximising the service users quality of life. The lack of training to NVQ level means that staff competency cannot be assured Recruitment and selection processes are to a good standard protecting vulnerable people. The lack of staff supervision and direction fails to ensure that the service users will receive consistent quality care. 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, since the previous inspection a number of NVQ qualified staff have left and training has been unable to keep pace and the 50 standard for NVQ staff is not met. Normal staffing levels are for 2 RMN, 4 carers and 2 activity co-ordinators during the day and a nurse and 3 carers overnight. Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 20 The registered manager has now terminated after a considerable absence and the formal supervisions have fallen behind and do not now meet the standard of 6 each year. Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 21 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 – 39 & 42 The acting manager is supported well by the staff, who demonstrate a good awareness of their roles and responsibility and identify with the leadership that ensures the team provide for the service users needs. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. EVIDENCE: The vacant manager post has been recruited and interviews are expected to take place shortly. In the interim the acting manager has maintained a good service, with high morale amongst the staff met during the inspection. The service undertakes extensive audits of the services provided which most often includes a formal survey of service users views, this aspect of quality assurance has not been undertaken in recent months. A full range of servicing, maintenance and regular monitoring of services and equipment is undertaken and staff receive training in health and safety and Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 22 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.V283363.R01.S.doc Version 5.1 Page 23 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 3 30 2 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 3 2 X X 3 X Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 24 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 YA14 Regulation 16(2)(n) Requirement The responsible person must ensure that social and recreational activities continue to be provided. The responsible person must provide a safe hot water supply at staff hand wash outlets and where necessary provide cleansing hand rub. The responsible person will provide sufficient access to NVQ training to ensure 50 of carers achieve level 2. The responsible person must reinstate the practice of formally supervising care staff at least six times each year. The responsible person must ensure that any quality assurance programme shall provide for consultation and seeking service users views. Timescale for action 30/04/06 2. YA30 13(3) 30/04/06 3. YA32 18(1)(c) 30/06/06 4. YA36 18(2) 30/04/06 5. YA39 24 30/04/06 Woodcross Mental Nursing Home (Highfields) DS0000039550.V283363.R01.S.doc Version 5.1 Page 25 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.V283363.R01.S.doc Version 5.1 Page 26 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.V283363.R01.S.doc Version 5.1 Page 27 - 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!