Inspection on 18/07/05 for Woodend

This inspection was carried out on 18th July 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodend 10/12/07

Woodend 30/11/06

Woodend 01/02/06

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 Announced 18 July 2005 th 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 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 F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodend Address Atherton Street, Springhead, Oldham, OL4 5TQ 0161 624 4739 0161 652 0764 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Gregory Leigh Ffynnonddeilog, Taliaris, Llandeilo, Carmarthenshire, SA19 7NF Miss Susan Leigh CRH Care Home 19 Category(ies) of DE(E) Dementia - over 65 Number 10 registration, with number OP Old Age Number 19 of places PD(E) Physical Disability - over 65 Number 1 SI(E) Sensory Impairment over 65 Number 1 Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Maximum number of persons accommodated - 19. Service users to include up to 19 OP up to 10 DE)(E) up to 1 S) (E) and up to 1 PD(E). Date of last inspection 12th January 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 Leigh’s sister. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection four service users were interviewed in private, as were three relatives of service users and three staff members. 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 staff rotas, medication records, maintenance records and the complaints log. ‘Comment cards’ were received from four General Practitioners and four relatives. What the service does well: What has improved since the last inspection? Several areas of record keeping, both in connection with care planning and health and safety issues were maintained more appropriately. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 6 The process for the administration of medication has improved. 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 F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 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 standard(s) 2, 3, 4 and 5. Service users’ needs are assessed before moving to the home. Service users are given a written statement of the terms and conditions and confirmation that the home can meet their needs. Service users or their representatives can visit the home before making a decision to move in. EVIDENCE: A selection of service users’ files was scrutinised. Each had evidence of an assessment having been undertaken by an appropriate professional, and a copy of the home’s terms and conditions. Service users who had moved to the home more recently also had written confirmation that, based on the assessment, the home could meet their needs. It is the policy of the home to encourage prospective service users to visit before making a decision to move in. Not all service users spoken to had taken advantage of this, although non had been denied a visit by the home. One Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 9 service user reported that a friend had chosen Woodend on her behalf and she didn’t regret the choice. One visitor confirmed that the service user’s family had chosen the home following a visit and one service user said he had chosen Woodend following a period of respite care. Woodend does not offer Intermediate Care. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Service users have individual plans of care. Service users’ health needs are met and the home’s policy and practices in connection with medication are appropriate. Service users are treated with respect and dignity and their privacy is respected. EVIDENCE: Each file scrutinised had a copy of a care plan and documentary evidence that the plan is regularly reviewed. In most cases service users had signed the care plan to signify their involvement in the planning and their agreement with the contents of the plan. It was reported that where there was no signature it was because the service user was unable to sign. Examples were seen where a good ‘social history’ had been recorded. This would assist staff to relate to the service user as a rounded individual. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 11 There was documentary evidence of service users having access to the full range of medical and para medical services available in the community. All GP comment cards expressed satisfaction with the overall care provided at Woodend. Similarly GPs reported that the home communicated clearly and worked in partnership with them. Service users and visitors who were asked, were confident that appropriate medical support would be obtained if necessary. Woodend used a pre dispensed monitored dosage system to administer service users’ medication. It was reported by the manger that they had recently changed to a different system following problems experienced from the previous one. Medication was seen to be stored appropriately. Medication administration records presented as being appropriately maintained. The manager reported some initial teething problems with staff’s use of the new system, but that the pharmacist was helpful in offering support and initial difficulties had been resolved. It was reported that no service user was administering their own medication, but, subject to a risk assessment, they could do so. One relative’s comment card indicated that they could not see their relative in private. However, the remaining ones indicated that privacy was not a problem. Similarly all GP comment cards confirmed that they could see their patients in private. Service users who were asked expressed the view that their privacy was upheld, and that they were treated with respect and dignity. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Service users are able to maintain their lifestyle and can exercise choice and control within the context of communal living. Visitors are made to feel welcome at the home. The quantity and quality of food is good. EVIDENCE: It was reported by the manager that organised, structured activities were not highly valued by the service users at Woodend. Consequently the staff team work with small groups or individuals. This is planned on a rolling basis to ensure each individual has the opportunity to engage in a social activity of their choice. Time spent ‘simply chatting’ to individuals is recognised as an important aspect of care and is valued as an important part of the daily work of staff. Two visitors questioned if there were enough activities at the home, but another identified “[staff] always doing something with them, makes you feel someone is there ”, as the best thing about the home. Service users who were asked, did not identify any problem with activities. One service user described the home as “nice and peaceful”. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 13 One visitor was particularly complimentary about the effort which staff put into festivals such as Christmas and Easter when all the staff turn up to help. The home has a policy which allows visiting at any reasonable time. Visitors spoken to confirmed this. Visitors also reported being made to feel welcome at Woodend, with one reporting that “people are very friendly, they offer a drink and are welcoming.” All service users, staff and visitors who were asked, believed that service users could exercise choice and control over their lives, within the context of individual capacity and communal living. Discussion with the manager indicated that the individuality of service users, and maintaining their independence was an important aspect of the ethos of the home. One service user said “… [its] free and easy, the staff are all very nice to get on with.” A meal was sampled, which was pleasantly presented and tasty. Meals can be taken either in the conservatory or in service users’ own rooms. All service users spoken to were complimentary about the food and one visitor identified the food as one of the best things about the home. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. There is an appropriate complaints procedure and service users believe complaints are taken seriously. Service users are protected from abuse. EVIDENCE: The home has an appropriate complaints procedure. The complaints log was inspected and presented as being appropriately maintained. All service users and visitors spoken to expressed the view that complaints would be responded to appropriately. An anonymous complaint received by the Commission for Social Care Inspection in connection with hygiene issues was partially substantiated at an unannounced visit in the weeks preceding this inspection. This related to some bodily fluids which had not been effectively cleaned from a chair in a service user’s bedroom. The home has a policy relating to the protection of vulnerable adults. Staff spoken to during the inspection demonstrated an understanding of the need to be vigilant in identifying poor practice. Similarly they demonstrated an understanding of the procedure for ‘whistle blowing’. All service users spoken to expressed the view that they felt safe at Woodend. This opinion was shared by visitors spoken to. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25 and 26. Woodend is appropriately maintained and decorated throughout, providing sufficient bathing, toilet and communal facilities. Service users are able to personalise their bedrooms, which are safe and comfortable. Some aspects of cleaning need to be undertaken more consistently. 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. Some double glazed windows had become misty and need replacing for aesthetic reasons. Some carpets were coming to the end of their useful life. It was reported by the manager that these were Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 16 scheduled to be replaced as part of the continual program of repair and renewal. 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 14 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. One service user, who was a wheelchair user, was in a room which was below the minimum standard for such service users. The service user confirmed that this was his choice as his move to Woodend was an emergency, but he knew the home and did not wish to go anywhere else. The manager confirmed that this was a temporary arrangement and he would be offered a larger room when one became available. Bedrooms were homely and showed appropriate levels of personalisation. At the time of this inspection the home was found to be clean and tidy, with no unpleasant odours. Visitors and service users spoken to during the inspection confirmed this was the usual state of the home. However an earlier visit in response to a complaint had identified some aspects of cleanliness which needed more thorough attention. These had been resolved by the inspection date. Service users who were asked, expressed satisfaction with their rooms and the facilities at Woodend. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. Staffing is provided to appropriate levels and the proportion of staff holding NVQ is good. Staff vetting during the recruitment process is not undertaken with sufficient rigor. Appropriate training opportunities are provided for staff. EVIDENCE: The staff rota for the week beginning 27th June 2005 was scrutinised. This demonstrated that a minimum of two staff were on duty throughout the day and night . During the day this increased to three or four in the morning and three during a period of the afternoon on most days. One respondent to the relatives comment cards expressed the view that there were not always enough staff on duty. However the other respondents disagreed. Service users spoken to did not identify staffing levels as a problem, and were complimentary about the responsiveness of staff. One reported “ Nothing is a problem and nothing a trouble, they [staff] don’t keep you waiting.” Another said “the girls will do anything for you, there is always someone there.” The manager reported that nine of the fourteen care staff had achieve NVQ II or above (this includes one carer awaiting formal confirmation of verification). Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 18 One other member of staff was undertaking NVQ II. A random sample of certificates was seen to verify this information. A selection of staff files was scrutinised. Whilst most of the records indicated that appropriate vetting had taken place examples were seen where this was not the case. The omissions related to one CRB (criminal record bureau) disclosure being obtained after the person started work and one example where a full employment history had not been obtained. A range of training opportunities was available for staff. Staff who were asked confirmed the availability of an appropriate range of training. Similarly they confirmed that the manager encouraged and supported training opportunities. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35, and 38. Good leadership is provided by the manager, resulting in an open and relaxed atmosphere in the home. Service users’ financial interests are protected by the procedures in the home. Appropriate procedures are in place to protect the health and safety of service users and staff. EVIDENCE: Discussion with staff and service users indicated an open, supportive and responsive management style. Regular, well attended staff meetings are held which have an open agenda. Offering a ‘service user’ centred approach to the running of the home and recognising the individuality of all residents is a fundamental philosophy of Woodend. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 20 All staff who were spoken to reported a positive ethos amongst the staff team, with good mutual support. One visitor commented on the commitment of staff and cited staff attending festivities even when off duty as an example of this. A selection of records relating to money held by Woodend on behalf of service users was scrutinised. They presented as being appropriately maintained to protect the interests of service users. Receipts were kept of expenditure made on behalf of service users. Service users (or their advocate) signed to confirm the receipt of cash. Records were examined relating to the regular maintenance and safety checks on equipment in the home, including fire protection and detection. These presented as being appropriately maintained. Staff confirmed the availability and mandatory use of disposable gloves and aprons to minimise the spread of infection. Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 x x 3 x x 3 Woodend F54 F04 5546 Woodend v231926 180705 Stage 4.doc Version 1.40 Page 22 yes 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 26 Regulation 16 (2)(j) Requirement Timescale for action 01/11/05 2. 29 19 (1) schedule 2 The registered person must ensure that any spillages of bodily fluid are cleaned immediately and thoroughly. The registered person must 01/11/05 ensure that no person is employed in the home until all the areas of vetting identified in the Care Homes Regulations 2001 have been addressed and documentary evidence is available. (Timescale from previous inspection 01/09/04 not met). 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. 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