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Inspection on 17/11/05 for Woodheyes Residential Home

Also see our care home review for Woodheyes Residential Home for more information

This inspection was carried out on 17th November 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The following are areas identified as good working practices; 1) 2) 3) 4) 5) 6) The appearance of caring and professional staff members Safe medication processes in place Clean and hygienic environment Good processes for promoting residents` choice A premise that is maintained to good standards Excellent care recordings

What has improved since the last inspection?

The outcome of the last inspection held earlier in the year was good. No issues were identified.

What the care home could do better:

No issues were identified during this inspection.

CARE HOMES FOR OLDER PEOPLE Woodheyes Residential Home 231 Hinckley Road Leicester Forest East Leicester LE3 3PH Lead Inspector Mr Everton Osbourne Unannounced Inspection 17th November 2005 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodheyes Residential Home DS0000001680.V265764.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. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodheyes Residential Home Address 231 Hinckley Road Leicester Forest East Leicester LE3 3PH 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) 0116 2387371 0116 2387398 Todaywise Limited Mrs Sheila Gladys Sheil Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (24), Sensory impairment (2) Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No-one falling within category SI(E) may be admitted into the home when there are two persons of category SI(E) already accommodated within the home. 1st June 2005 Date of last inspection Brief Description of the Service: Woodheyes care home cares for twenty-four older persons who have dementia, mental disorder and sensory impairment in a purpose built property situated along the main Hinckley Road leading to Leicester. The home is close to the city of Leicester where residents have access to a variety of facilities. The home is easily accessible for private and public transport. The premise consists of two floors accessible by use of the stairs and passenger lift. There are a variety of facilities in the home including dining and lounge space. The home comprises sixteen single bedrooms one without en-suite facility and four double bedrooms one without en-suite facility. A garden is situated to the rear of the premises. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took three hours to complete. The outcome of the inspection was good in that three residents spoken with gave positive verbal comments about their daily care. In addition to the three residents spoken with, two care records and other related documents were examined and one care staff member and the registered manager were spoken with as part of the inspection process. No Requirements or Recommendations were made. What the service does well: What has improved since the last inspection? 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. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 6 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 Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 7 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, 3 and 6 Good information is provided for residents about the care given in the home, which include a written contract for the protection of residents’ rights. The assessment process is robust in ensuring that residents’ care needs are identified. EVIDENCE: Discussion held with the registered manager indicated that the home’s Statement of Purpose remain up to date. An examination of the document indicated that accurate information about the care provisions is contained in the document. The registered manager indicated that prospective residents receive a copy prior to moving into the home. This was confirmed based on conversations held with three residents. An inspection of two residents’ assessments indicated that needs-led assessments were carried out prior to them moving into the home. Conversation held with these residents indicated that the documents reflect their assessed care needs. Discussion held with the registered manager indicated that the home does not provide intermediate (rehabilitation) care. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 8 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 and 9 The care plan and medication processes are effective in ensuring that residents receive good quality care. EVIDENCE: An inspection of two residents’ care plans indicated that all aspects of their care needs are being attended to. Good information is contained in the documents which gives staff members’ good instructions on how to meet these residents’ care needs. Three residents spoken with indicated that they are satisfied with the care provisions in the home. One resident commented ‘They look after us well’ (referring to staff members). Observation of the medication process indicated that staff members appear to be adhering to safe medication practices. Two residents’ medication records were inspected and found to be kept in order. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 9 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 Giving residents’ a choice over their own daily lifestyle is managed well so that residents can access recreational activities at their convenience. EVIDENCE: Observations made and conversation held with three residents indicated that they are able to participate in recreational activities at their convenience. Two residents’ care plans seen indicated that suitable recreational activities are being provided in the home. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 10 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): 17 There is an adult protection process to protect residents’ legal rights. EVIDENCE: Two residents’ care records seen and conversation held with three residents indicated that systems are in place so that residents can participate in voting processes and consult with advocates when required. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 11 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): 22, 23, 24 and 25 Residents’ surroundings are comfortable and clean to meet their accommodation needs. EVIDENCE: Two residents’ care plans seen and observations made indicated that all relevant adaptations and equipment are kept in the home for residents’ use. Observations made and conversation held with three residents indicated that they are satisfied with communal space in the home such as the dining and lounge areas. A tour of the premise indicated that adequate fixtures and fittings for example lighting fixtures in bedrooms and communal areas are in place. Observations made and conversation held with three residents indicated that there is sufficient water supply, heating, ventilation and lighting in the home. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 12 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 and 29 Adequate numbers of staff members are employed to work in the home for residents’ care and safety. The recruitment and training processes in place are good in ensuring that suitable staff members are employed for the care and protection of residents. EVIDENCE: The staffing rota seen and observations made indicated that there were adequate numbers and skill mix of staff members on duty at the time of the inspection. Three residents spoken with indicated that they are satisfied that a staff member is always available when needed. One staff member’s training record was inspected. The records seen indicated that the staff member has completed core training such as moving and handling and safe medication administration. Discussion held with the registered manager indicated that almost fifty per cent of the staff team have achieved their National Vocational Qualifications (NVQ 2) in care duties. Training records seen confirmed the registered manager’s verbal statement. One staff member’s recruitment record seen indicated that all relevant documentation such as two suitable references and a current Criminal Records Bureau disclosure are contained in the file. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 13 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, 32, 33, 34, 35 and 36 The home is managed well and staff members appropriately supervised for residents’ safety and care. EVIDENCE: An examination of the registered manager’s records indicated that the manager is qualified and experienced to manage this home. Conversation held with three residents and one staff member indicated that the manager’s approach to managing the home creates an inclusive atmosphere, which they feel is positive for the home. An examination of the quality assurance system indicated that questionnaires are given to residents and their relatives so that the home can receive feed back about the level of care given to residents. Discussion held with the registered manager indicated that the views of residents are asked for on a daily basis. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 14 An inspection of the financial procedures in the home indicated that the home does not manage residents’ monies. A certificate on display indicated that the home is suitably insured against loss or damage to the property and its contents One staff member’s records seen indicated that the registered manager regularly holds formal supervision with the staff member. Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 15 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 x x x x 3 3 3 3 x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 x x Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 16 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 Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Woodheyes Residential Home DS0000001680.V265764.R01.S.doc Version 5.0 Page 18 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!