Inspection on 17/07/07 for Woodgrange Care Home

This inspection was carried out on 17th July 2007.

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

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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 Woodgrange Care Home Westminster Lane West Road Bourne Lincs PE10 9TU Lead Inspector Julie Western Key Unannounced Inspection 17th July 2007 09:30 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 Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodgrange Care Home Address Westminster Lane West Road Bourne Lincs PE10 9TU 01778 424010 01778 393648 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) Barchester Healthcare Homes Ltd Mrs Helen Kathryn O`Leary Care Home 64 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (43), Physical disability (1) Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Burghley Unit accommodates up to 20 people within the categories DE(E) or MD(E) only. The Willoughby Unit accommodates up to 44 people within the categories of OP and PD only. The Maximum number of persons to be accommodated at Wood Grange Care Home is 64. Date of last inspection Brief Description of the Service: Woodgrange is situated on the outskirts of the town of Bourne, within walking distance of the local amenities such as shops, newsagents, hairdressers, Post Office, pubs etc. There is a local bus route, which runs past the home into the town centre and the home can also arrange transport. The home is part of a group of establishments owned and run by Barchester Health Care who purchased it in October 2004 and it was previously known as The Westminster Bourne; it was re-registered in February 2007 when the name was changed. A private drive leads to the home, which is a two-storey purpose-built modern establishment, standing in its own grounds. There is car parking to the front of the building and gardens with seating for residents to the rear. The home is registered to accommodate 64 nursing and residential people over the age of 65 years; 20 of these are in the Memory Lane Unit and are for people with Dementia or a defined Mental Health need and 44 are in the Willoughby Unit for older people with one of these currently being under 65 years and with a Physical Disability. Accommodation is in 61 single rooms and three shared rooms and on the day of the inspection the home was fully occupied. The home also has day care facilities for up to 7 people, who are accommodated throughout building. At the time of the inspection the manager confirmed that the weekly fees ranged from £383 - £750, depending on the assessed needs of the resident. Additional charges are made for services such as chiropody and hairdressing. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report is available in the reception area or the manager’s office. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took into account any previous information held by CSCI including the home’s previous inspection reports, its service history, any preinspection questionnaires completed by the Manager and any residents’ questionnaires sent to the home by the Commission prior to the inspection. The site inspection was unannounced, took place over four hours and consisted of tracking a sample of residents’ care records and assessing the care given. Some policies and procedures were examined and some records concerning the safety of the home were also seen. Three residents, three care and ancillary staff and two visitors were spoken with. The Manager was present throughout the inspection. What the service does well: What has improved since the last inspection? Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 6 The main entrance area has been altered and the reception area moved to create a sitting area. The bathrooms have been refurbished and several bedrooms have been upgraded. The gardens and in particular the entrance area have been made attractive with flower tubs and hanging baskets. The re-named Memory Lane unit for people with a dementia has shown a marked improvement; there are now one-to-one activities tailored to suit the needs of residents with a dementia and there were no unpleasant odours. The staff office has been enlarged and a window into the main lounge enables staff to continually monitor residents. Building work is currently in progress to add a conservatory off the main lounge. The room previously used for day care has been converted to a training suite, day care residents being incorporated within the main building. 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. The summary of this inspection report can be made available in other formats on request. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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 Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. EVIDENCE: The manager confirmed that the heads of the units usually visited prospective residents at home or in a care setting such as a hospital to undertake a thorough assessment of all their care needs. Records confirmed this. Residents spoken with had received prior information such as the statement of purpose and service user guide before admission. A visitor said she had been Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 9 given a list of issues to consider when looking around the other homes in the area, to enable her to make a decision on behalf of her relative. One resident said his relatives chose the home for him as he was too unwell to make decisions. Two others confirmed that they had visited the home for day care before living there permanently, so knew the home well before they moved there permanently. Written admission documentation was clear and gave staff the information needed to care for the residents. A staff member described the admission process and the importance of making new residents and their families feel welcomed. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s records give a clear picture of the health and personal care needs of the residents and enable staff t meet these needs with sensitivity and regard for their privacy and dignity. EVIDENCE: Care plans were comprehensive and well laid out. They contained details on how the health care needs of residents were to be met, including full risk assessments. Regular reviews took place and care plans were signed, showing the involvement of the residents and their supporters. Records showed that residents regularly saw their GP, practice nurse and, where necessary, consultant, opticians and dentists. A visitor said that his father’s health had improved since admission to the home some months ago. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 11 Medication records were clear and staff confirmed that only trained nursing staff administered medication. The last pharmacy visit was in September 2006 and there were no issues from this. The staff team were observed carrying out their duties with kindness and sensitivity, especially when attending to their personal needs. Residents in the Memory Lane unit with no verbal skills were communicating with well with staff members, holding hands with them and smiling at them. The manager said that there had been several meetings with the local GP’s and this had resulted in very good communications with the surgeries. A resident spoken with said ‘they’re like family really, they’re so kind’. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to choose from a wide range of activities and have a choice of meals from a balanced and varied menu. A lot of attention has been paid to ensuring that activities for residents with a dementia are suited to them and enhance their lives. EVIDENCE: The home has an activities co-ordinator and the week’s programme of activities is displayed in the entrance area. Regular activities included a crossword, looking at the daily newspapers, craftwork and board games. On the day of the inspection residents in the Memory Lane unit were listening to music and some were having a tasting session with chocolate; they were smiling and enjoying the occasion. The manager described how one resident who had not spoken for years was given a baby-size doll following investigations into her past history and was now much more communicative. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 13 Contact with families was seen as very important and family members were encouraged to stay with their relatives and eat meals with them. One resident regularly went home to his family at weekends. One resident whom a stroke had left able to speak only in Italian, her first language, had two members of staff who spoke Italian to assist her. The manager said that all staff members received specialist dementia training and she herself was shortly going to a course o dementia care mapping. All residents praised the food; one resident said ‘it’s like eating in a restaurant’ and a visiting relative said it was always beautifully presented. The dining room had menus at each table, which offered a choice of meals. The chef, who was a fully trained chef, said each resident was visited with the daily choice of menu in the morning and he received verbal feedback on the meals from residents when he went into the dining room afterwards. He was knowledgeable about special diets. Several service users had a pureed diet and this was presented to look appetising. Fresh fruit and vegetables were used and one visitor said that midmorning and afternoon the chef always sent round treats such as home made biscuits or prepared fruit snacks. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information on complaints is clear and gives residents and their supporters the confidence that comments and complaints will be listened to. Residents are kept safe from harm by clear policies and procedures. EVIDENCE: Residents spoken with said they had no wish to complain but would go to the manager if they did. A visitor said that she had had cause in the past to complain but she thought that the home was much improved; she said ‘the good practice from the new organisation has now filtered through’. Procedures for safeguarding adults were comprehensive and up to date. The complaints records showed that there had ben no complaints since the last inspection. Staff members spoken with said they had received training in safeguarding adults, which training records confirmed; the owner said there was a rolling programme of training for this. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a safe, comfortable and pleasant environment that is suitable for their needs. EVIDENCE: Externally, the building was maintained to a high standard, with large communal spaces. Recent improvements have included the creation of a sitting area in the main entrance/reception. The bathrooms have been refurbished and several bedrooms have been upgraded. The gardens and in particular the entrance area have been made attractive with flower tubs and hanging baskets. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 16 Dining rooms in particular were very pleasant places to eat in and had a restaurant atmosphere. Bedrooms were well personalised; one resident said ‘It’s not home but it’s the next best thing!’ Externally, the grounds were well tended and there were colourful flowers. The Memory Lane unit is currently being extended to provide a conservatory off the lounge; the manager said this would provide raised flowerbeds for sensory stimulation when complete. The home was clean and smelled fresh throughout. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are suitably trained, qualified and competent. EVIDENCE: The staff rotas showed that there were enough staff members to meet the needs of the residents. Staff members said they thought they had enough time to complete their tasks and residents confirmed this. Residents spoken with said the staff team was very good; one resident said ‘They’re all good’. A visitor said ‘Everybody’s smiling in this home’. The manager said that the organisation encouraged excellence in staff and an Employee of the Month award was given to the staff member voted top by residents and other staff. Two staff files were examined; they contained recruitment procedures, including criminal records and vulnerable adults checks. The most recent member of staff to be appointed described how she was interviewed, gave references and underwent an induction procedure. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 18 Staff members said that encouragement is given for training. The training plan showed that recent training had included moving and handling and specialist training in dementia. Records showed that two staff members had achieved the National Vocational Qualification, a nationally recognised qualification, with a further six working towards it. Two were working towards an award for assessors of this qualification and several were undertaking the NVQ dementia course. The staff member responsible for training said that the training programme and computer in the new training suite were linked to the head office and that funding for extra training was readily available. The computer also had an online link to local colleges for them to be able to mark any computer courses independently. Two of the trained nurses had specialist qualifications in continence issues. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for two months; she has been a registered general nurse since 1981 and has spent 27 years in social care; ten of these in management and three of these with Barchester homes. Residents and staff all said they had confidence in the manager and that she was approachable and accessible. Last month she was voted Employee of the month by staff and residents. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 20 There is a quality assurance system based on satisfaction questionnaires being sent to all residents and their families. Their replies are analysed and the results acted upon. The manager described how each unit was inspected by members of the management team. Follow up visits were then made to ensure any issues identified had been addressed. The manager received supervision from a regional director and there was a clear supervision structure for all other staff. Staff members confirmed they received regular supervision. There were residents’ meetings to which families were invited and which were recorded. All meetings and issues of quality assurance were sent to the head office for further audits to take place. Maintenance is identified and carried out by the home in conjunction with the head office and maintenance records are well documented. Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 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 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 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X X X X 3 Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 Woodgrange Care Home DS0000069218.V341118.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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