Inspection on 01/02/06 for Woodend

This inspection was carried out on 1st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodend 10/12/07

Woodend 30/11/06

Woodend 18/07/05

Woodend 12/01/05

Woodend 05/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Woodend Atherton Street Springhead Oldham OL4 5TQ Lead Inspector Steve Chick Unannounced Inspection 12:00 1st and 3 February 2006 rd 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 Woodend DS0000005546.V280428.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 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. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodend Address Atherton Street Springhead Oldham OL4 5TQ 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) 01616244739 01616520764 Mr Gregory Leigh Miss Susan Leigh Care Home 19 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (19), of places Physical disability over 65 years of age (1), Sensory Impairment over 65 years of age (1) Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 19 OP up to 10 DE)(E) up to 1 S) (E) and up to 1 PD(E). Maximum number of persons accommodated - 19. Date of last inspection 18th July 2005 Brief Description of the Service: Woodend is a small, detached residential home situated in the Springhead area of Oldham. It is registered to provide care for service users over the age of 65, in the following categories: dementia, old age, physical disability and sensory impairment. Accommodation is provided in nine single rooms, eight of which have en-suite facilities. The en-suites are shared with the adjoining rooms in four cases. There are five shared rooms, four of which have en-suites. A conservatory and two lounges provide communal rooms. Woodend is a privately owned, family run business, owned by Mrs T Kelly and Mr G Leigh (mother and son) and managed by Ms S Leigh, Mr Leighs sister. Woodend DS0000005546.V280428.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 on the first day. The inspector returned for a second visit by appointment, to talk with service users. Key standards which were not assessed at this inspection were found to have been met at the previous inspection. It is strongly recommended that this report is read in conjunction with the previous report from July 2005. During the inspection three service users were interviewed in private, as was one member of staff. Additionally discussions took place with the manager. The inspector also undertook a tour of the building and scrutinised a selection of service user and staff records as well as other documentation, including maintenance and fire precaution records. ‘Comment cards’ were received from four relatives. All service users spoken to, and comment cards received, expressed positive views about the service offered at Woodend. One relative described the home as “very friendly and caring” What the service does well: What has improved since the last inspection? The process for recruiting and vetting staff has improved and was found to be undertaken thoroughly and consistently. Improvements in the maintenance of records have been maintained. The overall good quality of care has been maintained. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 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. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 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 Woodend DS0000005546.V280428.R01.S.doc Version 5.1 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): None of these standards was assessed at this inspection. Woodend does not offer intermediate care. EVIDENCE: Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 9 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 and 10. Each service user has a written care plan which informs staff of their needs and assists in ensuring those needs are met. These plans are reviewed and updated to ensure this information reflects the changing needs of the service user. Service users’ privacy is respected and they are treated with respect. EVIDENCE: A random selection of service users’ files was scrutinised. All had a written plan of care with documentary evidence that the plan was reviewed on a monthly basis. There was evidence of care plans being amended following a review of the service user’s circumstances. The manager reported that service users were involved in the formulation, and when appropriate, the review of their care plan. This was supported by documentary evidence of service user involvement. Relatives reported that they were kept informed of important matters affecting their relative, and were consulted about their care. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 10 Other records relating to the implementation of the plan presented as being appropriately maintained. The staff member spoken to confirmed that they had sufficient, up to date, information to enable appropriate care to be offered to each service user. Examples were seen of useful ‘social histories’ which assist Woodend in offering a ‘person centred’ service. The manager and staff interviewed demonstrated an understanding of issues relating to ‘cross gender care’. It was reported by them, that this issue was handled with sensitivity, taking into account the wishes of the service users. Service users spoken to were positive about the care offered to them. All of the relatives ‘comment cards’ received reported satisfaction “with the overall care provided”. Service users were able to access their rooms at any time, or use the communal areas if they wished. All relatives ‘comment cards’ confirmed that they could visit their relatives in private. Service users spoken to reported that they were treated with respect and dignity by the staff. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 11 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): 13 Service users are able to maintain contact with family and friends to enhance their quality of life.. EVIDENCE: Woodend has a policy which enables people to visit the home at any reasonable time. All relatives ‘comment cards’ reported that they were welcomed into the home at any time, with one adding the comment “Very welcoming”. The manager and service users spoken to also confirmed the open approach to visiting. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 12 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 and 18. The home has appropriate complaints and protection procedures to maximise the opportunity for service users to live in a safe and responsive environment. EVIDENCE: Woodend has an appropriate complaints procedure. This was not scrutinised at this inspection, but had not been changed from previous inspections. Two relatives comment cards reported that, whilst not making a “complaint”, they had “asked questions” or had “more a query and wish”. In one case the relative reported that the home responded “immediately and I was very pleased and grateful”. In the other the relative reported that “I have asked questions and these were answered to my full satisfaction”. Service users and the staff member spoken to during the inspection reported that they were confident that any complaint would be taken seriously and responded to. Service users spoken to expressed the view that they were safe at Woodend. Since the previous inspection the Commission for Social Care Inspection had received an anonymous complaint about poor practice by one member of staff. On investigation this matter had been satisfactorily investigated by the manager who had taken appropriate action to protect service users. The home has a policy on ‘whistle blowing’. The member of staff interviewed demonstrated an understanding of the need to be vigilant and to take action if necessary to protect the interests of service users. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 13 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, 23 and 26. The home provides a clean and appropriately maintained environment for the safety and comfort of service users. There are sufficient bathing and toilet facilities to meet the needs of the service users. Service users can adapt their own rooms, within the context of health and safety requirements, to suit their own tastes. EVIDENCE: Woodend is a two story building. The first floor is the personal accommodation of one of the owners and does not form a part of this inspection. A tour of the building identified no significant issues requiring remedial action to the fabric of the building. In some areas in the corridor the décor was looking very tired. The manager reported that this was being scheduled for redecoration. Similarly the floor covering outside the kitchen needed to be Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 14 replaced. There was evidence that contractors had already been contacted to undertake this work. Woodend has two lounges and a conservatory which are pleasantly decorated and furnished. The building has large grounds, most of which would be inaccessible for people with restricted mobility. However there is a pleasant patio area which is accessible. Overall the building has a homely atmosphere. There are appropriate bathing and toilet facilities. Five of the fourteen bedrooms are double rooms, although several of the double rooms only had one occupant at the time of this inspection. Eight of the single rooms and four of the double rooms have en suite facilities, some of which are shared between two rooms. Bedrooms were homely and showed appropriate levels of personalisation. At the time of this inspection the home was found to be predominantly clean and tidy, with no unpleasant odours, although one bathroom had not been adequately cleaned after use. Service users spoken to during the inspection confirmed their satisfaction with the routine cleanliness of the home. Service users who were asked, expressed satisfaction with their rooms and the facilities at Woodend. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 15 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): 29. The home follows appropriate recruitment practices to minimise the risk of employing staff who may pose a threat to service users. EVIDENCE: A sample of documentation relating to staff who had been appointed since the previous inspection was scrutinised. All had evidence of appropriate vetting procedures being undertaken before the person started working at Woodend. These checks included two written references, a CRB (criminal record bureau) disclosure and POVA list check and a record of their employment history. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 16 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, 33 and 38. The manager’s experience and competence has a positive impact on the outcomes for service users. The Quality Audit and Quality Monitoring systems need some more work to ensure service users are aware of any improvement plans within the home. Health and safety procedures are appropriate to minimise potential risks to service users. EVIDENCE: The manager has extensive experience of managing Woodend over many years. Observation and discussion with staff and service users confirmed that she has maintained the open and service user centred ethos identified at Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 17 previous inspections. Discussion with the manager also indicated her competence and commitment to the service user group. There was good evidence of continuous quality audit procedures addressing a range of issues. These included periodically ascertaining the views of service users in a structured way. The small nature of the home and discussion with the manager indicated that these processes did influence the outcomes for service users. However, no written summary or action plan relating to the Quality Monitoring and Quality Audit findings had been produced. Appropriate health and safety procedures presented as being in place. Regular checks of the fire detection and alarm systems are undertaken and recorded. Staff confirmed the availability of disposable gloves and aprons to minimise the risk of cross infection. It was reported that staff receive ‘moving and handling’ training. This was confirmed by the staff member interviewed. The record of accidents in the home presented as being appropriately maintained. There was evidence of periodic audits of these records resulting in modification of practice within the home. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 18 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 3 Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 19 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 OP33 Regulation 24 Requirement The registered person must ensure that the Quality Audit and Quality Monitoring systems are collated and available for service users or their representatives, together with a written action plan based on the findings of the audit. Timescale for action 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations The registered person should ensure that all records relating to health and safety, including fire detection and alarm tests are recorded in a way which enables them to be easily accessed. Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Woodend DS0000005546.V280428.R01.S.doc Version 5.1 Page 21 - 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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