Inspection on 28/06/05 for Brendoncare Woodhayes

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Brendoncare Woodhayes 20/04/07

Brendoncare Woodhayes 19/01/06

Brendoncare Woodhayes 15/11/04

Brendoncare Woodhayes 09/06/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodhayes Nursing Home 36-40 St Leonards Road St Leonards Exeter EX2 4LR Lead Inspector Rachel Fleet Announced 28 June 2005 10:00 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. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodhayes Nursing Home Address 36-40 St Leonards Road St Leonards Exeter EX2 4LR 01392 667290 01392 667292 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) The Brendoncare Foundation Mrs Margaret Wendy Rendal-Jones Care Home 27 Category(ies) of OP Old age (27) registration, with number of places Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Notice of Proposal to Grant Registration for staffing/environmental conditions of registration was issued 15/3/1994 2 Registered for 27 - Elderly General Nursing Care 3 Registered for 8 Elderly Residents 4 Approved Person in Charge is Mrs Wendy Rendal-Jones RGN Date of last inspection 15 November 2004 Brief Description of the Service: Woodhayes Nursing Home is in central Exeter, in the residential area of St Leonard’s. The Home is a listed building, converted from two dwellings into one, and occupying a corner site. The grounds around the Home provide a pleasant outlook. There is a small area for car parking to the rear of the property, accessed from a side road. Local shops and bus routes are within level walking distance.A few steps lead up to the main entrance of the Home, although an alternative entrance has been provided for wheelchair access. There is level access throughout the ground and first floors of the home. A shaft lift provides access to the first floor, with a stair lift to a second floor flat. Residents requiring nursing care are accommodated on the ground and first floors. The second floor flat is for residents who have a degree of independence and require personal care only. All bedrooms have hand basin facilities. Full laundry and catering services are provided on site. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There were 25 residents at the Home on the day of the inspection. She visited twelve residents individually: one declined to speak with the inspector and five were unable to give their views in detail, but six spoke more at length. Comment cards were received from two residents in addition to those spoken with, and four other visitors/relatives. The inspector also spoke with a visiting relative, three care staff, the Manager, & Sam Foti, Care Support Manager, as well as looking around the Home and at some documentation. Records for three residents were used for case-tracking of care, etc. The inspector was at the Home for six hours, before sharing her findings with the senior staff. What the service does well: What has improved since the last inspection? No requirements were made at the last inspection, and the Home has addressed the recommendations made. Extra information has been added to the Statement of Purpose about the physical environment and the Registered Provider. Nutritional needs assessments inform care planning and reviews. The Home continues to address matters raised by individual residents – relating to food provided, involvement in decision making within the Home, access to inspection reports, for example, to ensure as much as possible that the Home is run in residents’ best interests. Systems for handling residents’ personal monies have been further improved. Emergency lighting is checked at intervals required by the local fire authority, and freezer temperatures are recorded, promoting the welfare of residents. A new shower room has been created, with easy access for wheelchair users. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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 Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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) 1 Prospective residents are given information they need to make an informed choice about where to live. EVIDENCE: Newer residents said they (or their family) received sufficient information prior to moving in. An updated Statement of Purpose was provided to CSCI with extra detail included. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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 & 10 Residents’ care is very well planned, providing staff with information they need to meet residents’ needs. Good health is promoted, residents benefiting from appropriate involvement of others to achieve this. Respect for residents and consideration of their privacy are part of daily life at the Home. EVIDENCE: Care records included social, psychological and physical health needs. They showed good communication with health-related professionals (GPs, Occupational Therapists, etc.) and follow-up of their advice. Various risk assessments were used to develop care plans. Evaluations were usefully reflective and detailed. Frailer residents who couldn’t give their views in detail looked well cared for. Residents or their representatives had been involved in care reviews. Although there is a payphone in the main corridor for anyone to use, residents may use the Home’s cordless phone in a more private place, if they wish. Residents said staff were generally respectful (-as observed during the inspection), ensuring their privacy when bathing, etc. They were able to remain in their own room, or return to it, whenever they wished. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 stage 4.doc Version 1.30 Page 10 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 & 15 Residents benefit from a varied programme of activities, which takes into account individuals’ needs and preferences. There are good links between the Home and the community around it. Meals provided are varied and balanced, with special dietary needs attended to and residents involved in review of how they can be made more to their liking. EVIDENCE: Most residents said there was sufficient for them to do in the day (- one resident wanted to go out more often). Activities organised by the Home included shopping, outings to local places of interest (at least monthly over the summer), use of the Home’s computer. Residents were enabled to attend local clubs, churches or attend the GP’s surgery. They spoke about the monthly newsletter. One person felt frailer residents might benefit from more one-toone opportunities for social activity or recreation. This was beginning to be addressed by the Activities staff, who are included in training programmes to enhance their skills. Some residents have been given communication books. This was greatly appreciated by one relative spoken with because it helped continuity of care and communication between staff, and with visitors. Regarding the food, one resident said it had improved though it was still variable, and others said it was good or acceptable. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 stage 4.doc Version 1.30 Page 11 A survey on the food provided had been carried out since the last inspection, following a recommendation made then, and it has been discussed at a recently introduced focus group, to ensure the Home is doing all it can to meet residents’ needs and wishes. Menus are balanced and varied. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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 & 18 The Home has a very good complaints system, with evidence that residents feel their views are listened to and acted upon. Appropriate action has been taken to try to ensure residents are protected from abuse. EVIDENCE: A record of complaints about various matters was seen, with details of action taken to address each one. The Manager responded to any complainant in writing. The complaints procedure was displayed in the main corridor. One staff said they had reported a resident’s concerns for them, in the role as their keyworker. CSCI has not received any complaints about the Home. Staff had appropriate knowledge regarding protection of vulnerable adults, and reporting of abuse should they ever encounter it. Relevant training had been given. There have been no allegations of misconduct or abuse in relation to the Home. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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 & 26 The environment is kept to a high standard, providing residents with a clean, pleasant and homely place to live, adapted to their needs. EVIDENCE: Residents were happy with their own accommodation, and did not have any issues to raise about the environment. The handyman was noted for his efficiency and helpfulness, attending at weekends if emergencies arose. The Manager was aware of a repair needed in one room. Bedrooms were very personalised, with individuals’ own possessions around them. A shared bathroom has been converted to a level access shower room, used independently by some residents. There were plenty of electric fans around the Home to keep residents sufficiently cool in the prevailing hot weather. Residents and a visitor said the Home was always kept clean. Staff said disposable gloves and aprons were always available for use. Laundry machines have recommended programmes for disinfection of laundry. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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, 29 & 30 There are good relationships between residents and staff, who clearly cared about residents’ wellbeing. Residents benefit from and are protected by the Home’s rigorous recruitment practices, and an active approach to training and supervision. EVIDENCE: There were six care staff on duty in the mornings, four in the afternoon/evening, and three overnight. A nurse is always included in these numbers. Staffing levels were generally felt to be sufficient – the majority of residents felt call bells were answered quickly enough (-one matter raised by a resident was discussed with the Manager). One said staff popped in at intervals to see they were alright in their room. One person was concerned that staffing levels did not match the number of residents currently needing help at meals, a difficult issue to resolve and being monitored by the Manager. One staff confirmed they had been through a full recruitment process and subsequently went through supervised induction. Randomly selected staff files contained required documentation. Nurses’ PIN numbers were checked. All staff have clinical supervision. Staff spoken with had an NVQ in Care or had recently undertaken training related to residents’ needs. The training programme and other events provided a variety of opportunities for rounded development of staff – management skills, etc. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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) 33, 35 & 38. Systems for consulting residents are good, with a variety of evidence that their views are sought and acted upon. The Home’s practices safeguard residents’ financial interests. Matters relating to the health and safety of residents and staff are very well monitored and managed, preventing or minimising possible risks. EVIDENCE: One resident said they wouldn’t hesitate to raise any issues with the Manager. Another who preferred not to attend residents’ meetings said the Manager came to see her instead, to discuss any matters she wanted to raise. A Focus group has been set up, where a few residents discuss particular topics relating to Home life, with a view to improving the quality of the service provided by the Home. Residents said they had had opportunity recently to speak with the Responsible Individual, who visits the Home at intervals. Some had raised concerns with him. One care staff said they would like to be included more in care planning, staff meetings, etc. but said they could discuss this during supervision. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 stage 4.doc Version 1.30 Page 16 Staff (including ancillary staff) have undertaken training related to Health and Safety matters. Windows randomly checked by the inspector had restrictors in place. The Manager confirmed all window restrictors were in place on upper windows, and regularly checked; it was recommended that checks be recorded, which the Manager began implementing during the inspection. Household cleaning products were stored safely. Equipment (hoists and extinguishers, for example) had recent service dates on. Checks for asbestos have been carried out. Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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 3 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 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 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. 1. Refer to Standard Good Practice Recommendations Woodhayes Nursing Home D54 D06_s26707_woodhayes_v225686_280605 stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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. 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