CARE HOMES FOR OLDER PEOPLE
Woodhall Park Risley Hall, Derby Road Risley Derby DE72 3SS Lead Inspector
Stuart Hannay Unannounced 22 June 2005 9:30am
nd 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. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Woodhall Park Address Risley Hall, Derby Road, Risley, derby, DE72 3SS 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) 0115 9490444 Mrs L I Crosbie Vacant CRH 41 Category(ies) of OP registration, with number of places Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 10th December 2004 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 C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Eight service users, 3 relatives and two staff members were interviewed on the day of the inspection. A brief inspection was made of the premises and a range of records relating to care and health and safety were checked. The medication system was checked. What the service does well: What has improved since the last inspection?
The home had completed risk assessments and all those checked were fully signed and dated. The complaints procedure had been amended to ensure that people were aware that they could report any concerns to the Commission for Social Care Inspection at any time. Bedside lighting was in place in the bedrooms checked. The home had copies of the guidance for the safe usage and storage of its cleaning materials. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 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 Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 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) 3 5 The needs of the service users are fully assessed prior to them entering the home. This ensures that the home is suitable and that staff can provide the care required. EVIDENCE: There was detailed information in the care plans seen which indicated that full assessments had been made prior to the service users entering the home. The assessment format, which forms the basis of the care plan, was seen by the inspector. It contained all the information required to make a full assessment to ensure that the home could reasonably assess whether they could meet the prospective service users’ needs. Service users and their relatives interviewed said that they had the opportunity to visit the home prior to coming in. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 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 standard(s) 7 8 9 10 The care plans ensure that the service users health and emotional needs are identified and met. Medication was generally safely stored and recorded but the issue of handwritten entries needs to be addressed. Service users said they were treated with dignity and respect. EVIDENCE: The three care plans checked were of a good standard. They contained a lot of useful information about the service users needs and were set out in a clear consistent format. The health needs of service users were clearly identified and showed what action staff needed to take to meet the needs. Contact with other professionals was fully documented. The plans also included information about service users’ psychological and emotional needs. Most parts of the care plans had been signed by most of the service users, however there were some gaps. For example, one service user who did not feel that she was taken to the toilet regularly enough, did have a detailed plan for continence management which had been followed, but she had not signed to say she agreed with this part of the plan. All of the service users interviewed said that they were happy for the staff to manage their medication. The medication was securely stored and the MAR (medication administration records) were fully completed to indicate whether medication had been given to service users. Some handwritten
Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 10 additions had been made to the pre-printed sheets which were not signed. The information written on by staff did not always reflect exactly what was typed on the printed prescription label on the bottle or box of medication. All the service users interviewed said that the staff treated them with dignity and respect, as did the 3 service users’ relatives spoken with. The staff were noted to be talking to the service users in a friendly and respectful way. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 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 standard(s) 12 13 14 Activities are provided for service users in line with their wishes. They can spend their days how they wish and contact with friends and family is encouraged. EVIDENCE: Service users said that there was a range of activities in the home, bi-monthly arts and crafts, sing-a-longs, games, bingo and visiting singers. They said that they could have visitors at any time they wished. Visitors confirmed that there are no restrictions on them coming into the home and that the staff keep them informed of their relative’s progress in the home. Service users said that they can get up in the morning at whatever time they wish and go to bed when they want. The standard on food was not fully checked but all the service users spoken with said it was good, with a good choice. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 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 standard(s) 16 The home has a formal complaints system and service users and relatives said that they had no problems raising concerns and that these would be addressed. EVIDENCE: The home had a formal complaints system which had clear timescales and reminded complainants of their right to contact the Commission for Social Care Inspection at any stage of the complaint. Service users spoken with said that they would not be afraid to make complaints and this was confirmed by relatives spoken with. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 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 standard(s) 19 20 22 The environment within the home was well maintained and clean providing a comfortable, safe environment which had been adapted to meet the service users’ needs. EVIDENCE: The home was clean and tidy on the day of the inspection and there were no unpleasant odours. Service users were able to use the lounges and were able to sit outside in the gardens and patio areas. There were hoists, handrails and assisted bathrooms to help service users to maintain their independence. Bedrooms were pleasantly decorated, highly personalised and have sufficient storage space. There were armchairs in the bedrooms checked. Service users said they were happy with their rooms. There were a lot of wheelchairs and one hoist stored in the TV lounge; whilst these did not cause a health and safety hazard, they detracted from the homely nature of the lounge. Some doors and skirting boards had been damaged by wheelchairs and need repainting or repair. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 14 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 Staff are deployed in sufficient numbers to meet the needs of the service users, however the home needs to discuss the perception of some service users and relatives that the home is sometimes understaffed. EVIDENCE: The senior nurse on duty said that the following levels were maintained: 2 Registered Nurses and 5 carers on the morning shift; 1 Registered Nurse and 4 carers on the afternoon shift and 1 Registered Nurse and 3 carers on the night shift. She said that these were increased by one extra carer on each day shift when the home was full. (There were 34 service users at the home on the day of the inspection). The manager, who would have been the second Registered Nurse was off sick on the day of the inspection and there was only 1 RGN on duty. Three service users spoken with and two of the relatives interviewed said that they did not feel there were always enough staff on duty to supervise the service users properly. On the two weeks rotas seen, the staffing levels were being maintained, except for the second Registered Nurse due to the manager’s short-term absence. One staff member interviewed felt that there were enough staff. It did appear that the home had sufficient staff to supervise the service users, there was no high incidence of falls or accidents, risk assessments were in place and the care plans recorded that needs were met. However the home needs to address the perception of some service users and their relatives that they are understaffed and must ensure that when numbers of service users increase again, the staffing hours are quickly brought up to the full complement.
Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 15 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 37 38 There is an open and friendly atmosphere at the home which encourages staff and service users to communicate their needs or concerns. Health and safety was generally well promoted but the home must ensure that procedures are followed consistently. EVIDENCE: Staff, service users and relatives interviewed said that there was a friendly, open atmosphere at the home. All said that they would have no hesitation in raising any concerns about any aspects of the service. They said that the manager and senior staff respond to any concerns seriously. The service users’ care plans, the fire training and fire testing records and the MAR (medication administration records) sheets were generally well-maintained. No obvious building hazards were noted during the tour of the premises. One staff member interviewed was able to clearly describe the fire procedure and confirmed that she had had training in fire safety, food hygiene, moving and handling, first aid and health and safety. Some tablets were left in a medicine
Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 16 tot in the lounge for around 20 minutes in the lounge without any staff present – these were removed when it was pointed out to a staff member. In two toilets, a disinfectant spray had been left out. The home’s administrator said that this was not hazardous but that normal practice was for it to be kept locked away. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 17 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 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x
COMPLAINTS AND PROTECTION 3 3 x 3 x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 x x x x 3 2 Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 18 No 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 OP9 Regulation 13 (2) Requirement Timescale for action 30/6/05 2. OP9 13 (2) 3. 4. OP19 OP38 23 (2) (d) 13 (2) 5. OP38 13 (4) (b) Handwritten entries on the Medication Administration Record sheets must be signed by the person making the entry. Handwritten entries on the 30/6/05 Medication Administration Record sheets must be an exact copy of the information on the printed label on the medication box or bottle. These entries should be countersigned by a second person as an accurate record. Damaged doors and skirting 30/10/05 boards must be repainted Medication must not be left 30/6/05 unattended in areas where it would be accessible to service users. All cleaning materials potentially 30/6/05 hazardous to service users must be kept locked away. 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
C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 19 Woodhall Park 1. 2. 3. OP22 OP7 OP27 4. OP27 Hoists and wheelchairs should not be stored in the service users communal areas. The service users should be consulted wherever possible when changes are made to their plan of care. A record of this consultation should be made. The manager should meet with interested service users and relatives to discuss their perception that the home is sometimes understaffed. this should include a discussion of how staff are deployed. Additional staff should be deployed when the number of service users increases. Woodhall Park C02 C52 S2126 WoodhallPark V226175 220605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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