Inspection on 07/02/06 for Woodfield Grange Nursing Home

This inspection was carried out on 7th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Woodfield Grange Nursing Home 09/12/09

Woodfield Grange Nursing Home 28/07/09

Woodfield Grange Nursing Home 04/02/09

Woodfield Grange Nursing Home 12/08/08

Woodfield Grange Nursing Home 17/07/07

Woodfield Grange Nursing Home 14/08/06

Woodfield Grange Nursing Home 15/09/05

Woodfield Grange Nursing Home 19/01/05

Woodfield Grange Nursing Home 29/09/04

Woodfield Grange Nursing Home 23/03/04

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

CARE HOMES FOR OLDER PEOPLE Woodfield Grange Nursing Home Saddleworth Road Greetland Halifax West Yorkshire HX4 8NZ Lead Inspector Lynda Jones Unannounced Inspection 7th February 2006 9:00 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 Woodfield Grange Nursing Home DS0000001076.V265900.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. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodfield Grange Nursing Home Address Saddleworth Road Greetland Halifax West Yorkshire HX4 8NZ 01422 377239 01422 311863 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) Ancyra Health Limited Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: Woodfield Grange is a care home with nursing providing accommodation and care for 36 older people. The home is situated on Saddleworth Road and is approximately ½ mile from the local shops and facilities in West Vale. The home is set in its own attractive gardens and there is a patio area to the front of the building where service users’ can sit in fine weather. There are carparking facilities to the side of the building; the car park is on a very steep slope. Accommodation at the home is arranged over three floors. There is one very large lounge on the ground floor and a separate dining room. There are also four small sitting areas, two each on the ground and lower ground floors, which are located in the corridors. Each floor can be accessed by passenger lift. There are 34 single bedrooms and one double bedroom. None of the bedrooms have en suite facilities. There are four bathrooms in the home and a separate shower room, in addition, there are nine separate toilets located around the building. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk The last inspection of the home was unannounced and took place on 15 September 2005. This was an unannounced inspection carried out by two inspectors over 5.45 hours. The main purpose of the inspection was to make sure that the home provides a good standard of care for the people who live there. The methods used at this inspection included looking at care records and health and safety records and talking to the manager. A tour of the building took place and time was spent talking to service users and the staff on duty. The last inspection report was not very positive. It is therefore very encouraging to see that the new manager (who had only been in post for one month at the time of this inspection) has already begun to address some of the areas that caused concern. This report acknowledges the improvements that are already underway. Proposals for future developments are encouraging. What the service does well: The staff are friendly and welcoming. Service users say the staff are helpful and patient. The home is clean and bedrooms are personalised. There is evidence that service users have their personal possessions around them in their rooms. Care is taken to make sure service users clothes are laundered appropriately. The pre admission assessments are good. A range of activities are on offer. The Coordinator makes sure she spends time with all service users. Records of activities are good. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 6 The manager has only taken up post recently but she has a good understanding of areas that need to improve in the home and a clear development plan for the home. What has improved since the last inspection? What they could do better: The appearance of the bathrooms could be improved. Not all of the bathing facilities can be used. Service users cannot get in and out of some of the baths. The shower is not useable. This needs to be addressed. Some of the bedrooms need redecorating. The window frames need repainting. Bedroom windows should not be left open for long periods during the day as this makes the rooms quite cold and some service users may wish to spend time in their rooms. Safe moving and handling techniques must be used at all times. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 7 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. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 8 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 Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 9 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): 3 All prospective service users are assessed before they move into the home. This makes sure that the staff are able to give people the support they need. EVIDENCE: Prospective service users and their families are welcome to call at Woodfield Grange at any time to meet people who live there and to view the accommodation. Once a referral is made to the home, the manager meets and assesses each individual to make sure their needs can be met. A sample of files relating to people who had recently moved into the home was examined. The pre admission information that had been gathered was good. It was noted that Calderdale assessments were in place for those people referred by the Local Authority. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 10 Once the manager is satisfied that the home can meet individual needs, she telephones people to confirm that a place can be offered. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 11 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 There has been a significant improvement in the standard of care plans since the last inspection. The new care plans clearly show what action the staff must take to ensure that the needs of service users are met. EVIDENCE: The manager is systematically working through the old documentation and is transferring information into a care plan format that has been recently adopted at the home. There was evidence that information from the initial assessment was used to form the basis of the care plan. The plan sets out in detail the action that staff need to take to ensure that the health, personal and social care needs of each person are met. There was evidence that service users and their relatives had been consulted and involved in the gathering of information. Evidence also indicated that the plans were regularly reviewed. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 12 It was good to see that the practice of queuing for the downstairs toilet before mealtimes had ceased. It was also good to note that the wheelchairs that were used had footrests in position for the safety of service users. Where footrests were not in use there was good reason. This had been a concern at the last inspection. Other areas of improvement noted by inspectors included staff taking time to assist people to walk if they were able to do so, rather than over reliance on the use of wheelchairs. The manager said that plans are in place to take a more pro-active approach to the continence needs of service users. Staff are now positively encouraging and assisting people to use the toilet if they are able to do so. Reviews of medication are underway to ensure that service users are not given medication that they don’t need. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 13 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): 12 An activities coordinator has been appointed. The plans for activities are inclusive; all service users will have opportunities to participate in activities of their choice. EVIDENCE: An activities coordinator has recently been appointed. This is a very positive initiative on the part of the home. The coordinator keeps a detailed record of all social activities that take place. The records are prefaced by a photograph of each service user. They go on to include details of the date, duration and type of activity taking place. Records show that a variety of activities have taken place and that everyone has the opportunity to take part. Some service users prefer not to take part in group activities and their needs can often be overlooked. It was pleasing to note that this is not the case at Woodfield Grange, the coordinator has ensured that she spends time individually with all service users either chatting and getting to know them or assisting them to participate in a hobby or pastime that they enjoy. This is demonstrated in the records. During the course of the day, armchair exercises and hand massages took place. The coordinator also spent time with one person looking at a book about Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 14 the history of Coronation Street and reminiscing about the characters who had appeared over the years. There are plans to accompany people on trips out when the weather improves. Transport has already been booked from May, through the summer months. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 15 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): EVIDENCE: Not assessed on this inspection. See last report. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 16 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): 19,21,24,26. The domestic team work hard to maintain good standards of cleanliness and hygiene throughout the home. All of the bedrooms have been personalised and reflect the needs and tastes of service users. Some bedrooms need to be redecorated. Bathing facilities at the home need to be improved. The bathrooms are not particularly inviting and service users can use not all of the baths. EVIDENCE: The Fire Safety Officer visited the home in January 06 and provided a report with details of work that needs to be carried out in the home. Ancyra Health Limited, the registered providers, have authorised the work. A requirement is made in this report for this work to be completed. The score on this standard is to reflect the fact that this work that is outstanding. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 17 The home has a good team of domestic and laundry staff. They work hard to make sure all areas are clean and tidy and to make sure that care is taken with service users clothes. All of the bedrooms have been personalised by service users with the help of their relatives and staff. Most contain photos, ornaments and plants. There is evidence that people have their own toiletries and these are kept in their rooms. The bed bases would look better if they were hidden by valances. On a tour of the building it was noted that a number of small jobs need to be completed by the homes handyperson. These included repairs to a window fastener, bed safety rail, drawer handles and tap tops. Some of the carpets in bedrooms need attention where they are uneven and could be tripped over by service users. An audit of all the decoration in bedrooms would be useful, in many rooms the wallpaper is peeling from the wall. There appears to be a shortage of curtain hooks throughout the home. The curtains are not hung properly in many of the rooms. There are five baths and a shower in the home, although not all of these facilities are suitable to be used by service users. Some baths do not have hoists and service users cannot get in or out, the shower is not useable. An action plan is called for in this report, showing how the registered providers propose to address this. The temperature on the corridors in different parts of the home varied considerably with temperatures ranging from 61° to 71°. This reason for this needs to be investigated. This needs to be monitored to make sure that service users are warm enough. During a tour of the building it was noted that many of the bedroom doors were propped and wedged open. The windows in the bedrooms were open and the rooms were cold. Staff need to consider the impact that this could have on service users. The temperature in the bedrooms would most likely discourage service users who are able to do so, from returning to their rooms during the day. The external window frames are all in need of attention, the paint has flaked off many of them leaving the bare wood exposed. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 18 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): 27,30. There has been an improvement in the staffing situation at the home. Staff training needs will be highlighted through the proposed supervision system. EVIDENCE: The staffing notice issued by the previous regulatory authority shows that for between 31-35 residents there should be 6/7 members of staff on duty during the day and 3 members of staff on duty at night. One member of staff must always be a qualified nurse. The manager said that these staffing levels are now being met at the home. This is an improvement on the situation at the time of the last inspection. Two new care staff have recently been recruited, they will start work at the home once checks have been carried out with the Criminal records Bureau. An additional member of staff has been recruited to take up domestic/laundry duties and a Criminal Records Bureau check is awaited. The manager reported that she had worked several shifts in order to get to know service users and to observe care practice at the home. She said she had found this very helpful in getting to know people. It is good to see that the manager is able to work in a supernumerary capacity. This has enabled her to begin to address some of the shortfalls that were highlighted at the last inspection. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 19 New personnel files and staff training files have recently been set up, making it much easier to access information. The following staff training is scheduled in the next two months, Health and Safety in the Workplace, First Aid, Fire Safety, Control of Substances Hazardous to Health (COSHH) and Moving and Handling. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 20 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): 34,37,38. The manager has a good understanding of the areas in which the home needs to improve. The plans to address these areas are promising. Health and safety documentation at the home is satisfactory. There are signs of a general improvement in the standard of record keeping. Despite training, unacceptable methods of moving and handling were used by staff at the home. EVIDENCE: The manager has been in post since the beginning of January 2006. She is a qualified nurse with considerable experience of management in the care sector. She has been employed in the past as Operations Manager for a large group of homes for older people. The manager has applied to be registered by the Commission for Social Care Inspection; her application is currently being processed. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 21 The home does not hold money for service users. Relatives are invoiced for hairdressing and chiropody services that service users have used. The care plans include details of any Power of Attorney arrangements Care plans contain inventories of service users’ possessions and detailed descriptions of property are recorded. The home has a health and safety policy in place and workplace risk assessments have been completed. Fire test records, lift maintenance records and gas safety documentation were examined and found to be up to date. The record of accident records was examined. Staff need to be reminded to record details in full, including where accidents take place in the home. Preparations are underway for staff to undertake a range of health and safety related training (see standard 30). Plans are in place to provide annual appraisals and regular supervision for all staff at the home. This is a positive move on the part of the new manager. Many of the staff at Woodfield Grange have received training on how to transfer service users safely from chairs to wheelchairs and how to safely assist people to move from sitting to standing positions. Staff have also been provided with appropriate equipment to use to assist service. It was therefore entirely unacceptable to see staff not using the equipment and repeatedly using unsafe methods of moving and handling service users. This was brought to the attention of the manager and she spoke to the staff on duty. Thereafter, staff assisted service users appropriately. This is a serious issue that could result in injury to service users and staff. A requirement has been made in this report for all staff to receive additional training in safe moving and handling. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 22 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X 1 X 3 X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 X X 3 1 Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 23 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 2 3 Standard OP19 OP21 OP38 Regulation 23 23 13 Requirement The work outlined in the Fire officer’s report of January 2006 must be completed. An action plan is required, showing plans to improve the bathing facilities in the home All staff must receive refresher training in moving and handling techniques. Timescale for action 31/08/06 31/03/06 30/04/06 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 2 3 Refer to Standard OP19 OP19 OP19 Good Practice Recommendations All areas of the home should be audited to identify where redecoration is required. Bedroom windows should not be left open for long periods during the day. Action should be taken to ensure that a comfortable, even DS0000001076.V265900.R01.S.doc Version 5.1 Page 24 Woodfield Grange Nursing Home temperature is maintained on the corridors. Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Woodfield Grange Nursing Home DS0000001076.V265900.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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