Inspection on 14/09/05 for Woodhall Park

This inspection was carried out on 14th September 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodhall Park 23/01/08

Woodhall Park 19/10/06

Woodhall Park 22/06/05

Woodhall Park 24/06/04

Woodhall Park 08/07/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Woodhall Park Risley Hall Derby Road Risley Derby DE72 3SS Lead Inspector Anthony Barker Unannounced Inspection 14th November 2005 1:20 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 Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 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. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodhall Park Address Risley Hall Derby Road Risley Derby DE72 3SS 0115 9490444 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) Mrs L I Crosbie Vacant Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one named service user under the age 65 for the duration of their care. 22nd June 2005 Date of last inspection Brief Description of the Service: The Home provides nursing for up to 41 older people. It is situated in an appropriately adapted building, in a pleasant park setting in Risley. It is situated near to public transport. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 5.25 hours and was a routine unannounced inspection. The last inspection took place in June 2005 and was unannounced. Three residents, the person-in-charge/senior staff nurse and the Acting Manager were spoken to, records were inspected and there was a tour of the premises. No residents were case tracked on this occasion. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Amendments must be made to the Home’s Statement of Purpose. The recording and administration practices regarding medication must be improved. Refurbishment of certain parts of the Home is needed and this includes addressing the Fire Officer’s requirements. A loop system for service users with hearing impairment must be fitted. Improvements to the en-suite facilities and the lighting must be made in certain bedrooms and door locks fitted in all. Bedrooms must be free from offensive odours. Systems to Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 6 provide TOPSS-certified staff induction training and formal supervision must be in place. Required monthly monitoring visits by, or on behalf of, the registered provider must be started and maintained. Risk assessments must be recorded to address the hazards posed by scalding hot water and documentation describing first aid measures must be kept near to cleaning materials. 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. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 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 Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 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): 1, 2 & 3 Although residents had access to a Statement of Purpose for the Home this was not up-to-date. Residents had their needs assessed thoroughly before admission to the Home. EVIDENCE: The Home’s Statement of Purpose had been amended to reflect the environmental standards. However, it had not been changed to reflect the appointment of the current Manager. The statement of Terms & Conditions/Contract supplied by the Home was not available for inspection so it was not possible to see whether it had been updated to include all the information listed within National Minimum Standard 2.2. The pre-admission assessment documents included all the items listed in Standard 3.3. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 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&9 Residents’ health, personal and social care needs were set out in welldocumented individual plans of care. Residents were not being protected by the Home’s practices regarding the administration of medicines and the recording of these. EVIDENCE: There was evidence that residents were being involved in the drawing up and review of their care plans. The Acting Manager explained that relatives are involved if the resident is unable. Risk assessments were being written, including those specific to falls. The documents examined at this inspection were being dated and signed. Bi-monthly care plan audits were being undertaken by the Acting Manager. This was evidenced by care plan audit lists. The Home’s trained nurses were ‘link nurses’ for topics such as palliative care and continence promotion. Resident continence assessments were being regularly reviewed. Other aspects of Standard 8 were not assessed on this occasion. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 10 Handwritten entries on the Medication Administration Record (MAR) sheets were an exact copy of the information on the printed label on the medication box/bottle. However, these handwritten entries were not always being signed by the person making the entry and countersigned and one entry was not dated, either. One resident’s MAR sheet indicated a dose of warfarin twice that prescribed, on one day, and some other entries were confusing to read. A large number of gaps on MAR sheets were also noted. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 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): 12 & 15 Daily routines were flexible and residents were offered a range of stimulating activities. Residents received a wholesome balanced diet. EVIDENCE: The Acting Manager said that the Home had appointed a full-time activities co-ordinator one month ago. A diary is kept of the wide-ranging activities arranged. One example of these was a trip out to a local manor house – for lunch and entertainment - on the day of this inspection. The Acting Manager added that this post had released care staff from activities duties. There was discussion with the person-in-charge and, later, the Acting Manager about a complaint received by the Commission concerning alleged inflexibility insensitivity with early morning routines. The Inspector was satisfied with their responses and noted that the Acting Manager displayed positive attitudes towards flexible resident-oriented routines in the Home. The completed preinspection questionnaire indicated that breakfast took place over a period exceeding two hours each morning. The two-week rolling menu showed an appetising and nutritious range of meals with a recorded choice of two each lunchtime. Three residents were spoken to about the quality of the food at the Home and all were most positive. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 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 & 18 Residents were benefiting from an effective complaints system and were being protected from abuse. EVIDENCE: One complaint had been made about the Home in the past 12 months and, as mentioned, this was discussed at this inspection as well as a written response made to the Commission. The complaint was found to be partially substantiated. The Inspector was satisfied with the written response and felt that the matter had been dealt with professionally and sensitively. The Home’s written complaints procedure had been improved and was satisfactory. One resident said he was very happy that he could share any grumbles with staff. Staff were receiving training in Adult Protection matters, as part of a rolling programme. All but two care staff had completed the Derbyshire one-day course, the Acting Manager said, and nursing staff were being placed on two day courses. Written guidance to staff, on adult protection matters, had been provided as part of the Home’s ‘Policy on Abuse’ and the Derbyshire Procedures were also available to staff and covered in induction training for new staff. The Acting Manager said she was link nurse for adult protection matters. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 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, 22, 24, 25 & 26 Residents were not fully benefiting from a safe and well-maintained environment. They did not have all the equipment and facilities they required to meet their independence and privacy needs. Residents’ safety was being potentially compromised through inadequate lighting in bedrooms. The Home was hygienic except for an offensive odour in one room. EVIDENCE: The dining room and twelve bedrooms had been redecorated since the last inspection. The ‘Peach Lounge’ had not been redecorated as required. Also, some doors and skirting boards remain damaged. The Fire Officer had noted damage to the seals on some fire doors and had required action on these. New signs for the Home had been placed so that visitors could locate the Home easier. Two new hoists had been bought in July 2005. Hoists and wheelchairs were still being stored in residents’ communal areas. There was discussion with the Acting Manager about possible alternative storage areas. The Acting Manager said that a loop system for residents with hearing impairment had not been Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 14 fitted but a cost had been identified. She also explained that the two en-suite shower cubicles, identified at the last inspection, that could only be accessed by stepping up to them were not used by the residents in those rooms because of their degree of dementia. This requirement remains in this report. The Acting Manager confirmed that locks had still not been fitted to bedroom doors and there was no note on care plans of the matter being discussed with residents. There were lockable facilities in just two bedrooms. The Acting Manager also confirmed that the majority of residents receiving nursing care had been provided with adjustable beds. One of these was seen on a tour of the premises and it had an appropriate domestic appearance. The ceiling lighting in one bedroom was poor – with only a 60 watt bulb. The Acting Manager said one of the trained nurses was link nurse for infection control matters. There was a strongly offensive odour in one bedroom although, as the Acting Manager reported, the carpet was shampooed daily. The wooden shelves in the sluice rooms had been replaced with metal ones, the Acting Manager reported. The vinyl flooring in toilet 32 had been replaced for reasons of hygiene. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 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): 27 & 28 Residents’ needs were being met by satisfactory numbers of staff although improvement was needed to the levels of recruitment and rate of staff turnover. Residents were not benefiting from a group of care staff who had received induction/foundation training to accepted standards. EVIDENCE: The Acting Manager said that she found it difficult to attract care staff to the Home and therefore used agency care staff fairly consistently - on average, 30 shifts a week. Seven staff – five care staff and two ancillary staff – had left the Home since the last inspection in June 2005. At the time of this inspection there were at least five staff vacancies and three staff were on long-term sick leave. The Acting Manager described a range of efforts being made to improve the levels of recruitment. She also confirmed that she was providing staffing levels to the Residential Forum’s suggested formula. It was pointed out to her that this did not apply to staffing in nursing homes and it was agreed that a copy of the Staffing Notice for the Home, in force at 31/3/02, would be sent to her together with a copy of the Derbyshire minimum levels for ancillary staff, in force at 31/3/02. The Acting Manager said she had deployed an extra member of care staff on the early shift since resident numbers had increased. She added that she had met with residents and relatives to discuss their perception that the Home is sometimes understaffed. New staff induction/foundation training records, that met the Training Organisation for the Personal Social Services (TOPSS) standards, had just been Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 16 introduced. One was seen for a recently appointed member of staff but little had been recorded on the sheets. 15 of the care staff had achieved a National Vocational Qualification (NVQ) at level 2. It had been recommended at a previous inspection that an action plan should be produced to identify how it is intended to ensure that 50 of trained members of care staff (NVQ 2 or equivalent) is achieved by 2005. This was not assessed at this inspection. The Acting Manager said that the Home’s system of interviewing new staff had changed and that she and the Home’s Administrator now undertake this task. Other aspects of Standard 29 were not assessed on this occasion. The Acting Manager said that staff receive twice yearly fire training from an external trainer and one of the trained nursing staff provides fire training for newly appointed staff. Other aspects of Standard 30 were not assessed on this occasion. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 17 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, 36 & 38 Residents were benefiting from an experienced and competent manager. Staff were not being appropriately supervised. The health and safety of residents and staff was not being fully protected. EVIDENCE: The Acting Manager was appointed on March 1st 2005. At the time of this inspection she had applied to be the registered manager and was awaiting the outcome of her application. She is an experienced manager and first level registered nurse. She is currently undertaking NVQ level 4 Registered Managers Award training which she commenced in March 2005. She said she aims to allocate two working days a week to administrative duties and the rest to working beside staff. She spoke of there being no problems with unclear lines of accountability within the Home. The Acting Manager spoke of one Relatives’ Meeting being held and two Residents’ Meetings, since she was appointed. Minutes had been made of Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 18 these meetings but these were not available at the time of this inspection. Other aspects of Standard 33 were not assessed on this occasion. Formal staff supervision had still not been started and there was discussion with the Acting Manager about the requirements of Standard 36. A system was in place for periodic staff appraisals. There was no evidence of monthly visits, complying with Regulation 26, taking place to the Home. Other aspects of Standard 37 were not assessed on this occasion. The water from wash hand basin hot taps in several bedrooms and in one WC was scalding hot. The Acting Manager confirmed that mixer valves were fitted beside all baths but not wash hand basins. There were still no cleaning materials product data sheets in the main cleaning materials store – only in the office. No other health and safety problems were found. Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 19 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X 2 2 2 STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 2 X 2 Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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. Standard OP1 OP9 Regulation 4 Sch 1 13 (2) Requirement The Registered Person must amend the Statement of Purpose to include the current Manager. Handwritten entries on the Medication Administration Record sheets must be signed by the person making the entry. (Previous timescale was 30/06/05) Handwritten entries on the Medication Administration Record sheets must be signed, countersigned and dated. The registered person must ensure that all medicines are administered as per the dosage recorded on the MAR sheets. There must be no gaps left on MAR sheets. Use must be made of the proper codes if medication is not administered. Redecoration of peach lounge, as detailed in this report, must be undertaken. (Previous timescale was 01/02/05) Damaged doors and skirting boards must be repainted (Previous timescale was 30/10/05) DS0000002126.V262333.R01.S.doc Timescale for action 01/01/06 01/01/06 3. OP9 13 (2) 01/01/06 4. OP9 13 (2) 01/01/06 5. OP9 13 (2) 01/01/06 6. OP19 23(2)(d) 01/03/06 7. OP19 23 (2) (d) 01/03/06 Woodhall Park Version 5.0 Page 21 8. 9. OP19 OP22 23(4) 22(2)(n) 10. OP24 23(1)(n) 11. OP24 16(2)(c) 12. OP25 16(2)(c) 23(2)(p) 13. 14. OP26 OP28 16(2)(k) 18(1)(a) 15. OP36 18(2) 16. OP37 26 17. 18. OP38 OP38 13(4) 13(4)(c) The registered person must take action on the Fire Officer’s requirements. A loop system for service users with hearing impairment must be fitted. (Previous timescale was 01/02/05) En-suite facilities, in rooms accommodating disabled residents, must be accessible to them. Locks suited to service user’s capabilities and accessible to staff in emergencies must be fitted in service users private accommodation. (Previous timescale was 30/11/03) Lighting in bedrooms must be adequate to ensure the risk of tripping is minimised and residents, who wish, can read without straining their eyes. (Previous timescale was 01/12/04) All parts of the Home must be kept free from offensive odours. New care staff must be provided with induction/foundation training that meets the Training Organisation for the Personal Social Services (TOPSS) standards – as evidenced by records maintained in the Home. A supervision policy and system must be introduced to ensure that supervision of care staff takes place at least six times a year. (Previous timescale was 31/10/03) Monthly visits complying with Regulation 26 must take place to the home and documentary evidence of these be kept at the home for inspection. Risk assessments must be recorded regarding the hot water supplied at all wash hand basins. Cleaning materials product data DS0000002126.V262333.R01.S.doc 01/04/06 01/02/06 01/05/06 01/04/06 01/01/06 01/01/06 01/01/06 01/02/06 01/01/06 01/02/06 01/01/06 Page 22 Woodhall Park Version 5.0 sheets must be kept in the main cleaning materials store, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations. (Previous timescale was 01/11/04) 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 OP2 Good Practice Recommendations The statement of Terms & Conditions/Contract supplied by the home should be updated to include all the information listed within National Minimum Standard 2.2 (This recommendation was from an inspection dated 2/12/02) Hoists and wheelchairs should not be stored in the service users communal areas. (This recommendation was from an inspection dated 22/06/02) Induction and foundation training should meet with National Training Organisation (NTO) workforce training targets. (This recommendation was from an inspection dated 2/12/02) An action plan should be produced to identify how it is intended to ensure that 50 of trained members of staff (NVQ 2 or equivalent) is achieved by 2005. (This recommendation, from an inspection dated 8/7/03, was not assessed) Mixer taps should be fitted beside all wash hand basin hot water taps used by residents to ensure that the water does not exceed a temperature of 430C. 2. 3. OP22 OP28 4. OP28 5. OP38 Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Woodhall Park DS0000002126.V262333.R01.S.doc Version 5.0 Page 24 - 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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