Inspection on 12/09/05 for Woodhorn Park

This inspection was carried out on 12th September 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

Woodhorn Park 04/06/07

Woodhorn Park 05/09/06

Woodhorn Park 20/02/06

Woodhorn Park 04/03/05

Woodhorn Park 23/09/04

Woodhorn Park 04/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Woodhorn Park Woodhorn Road Ashington Northumberland NE63 9AN Lead Inspector Jim Lamb Unannounced 12 September 2005 9:30 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. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodhorn Park Address Woodhorn Road Ashington Northumberland NE63 9AN 01670 812333 01670 812666 woodhorn@barchester.com Barchester Healthcare Homes Limited 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) Mrs Cynthia Ann Davidson CRH 60 Category(ies) of DE(E) - Dementia - Over 65 (23) registration, with number OP - Old Age (37) of places Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4 3 05 Brief Description of the Service: Woodhorn Park is a large sixty bedded home providing personal care and accommodation for older people. This is a pupose built home and is situated in the town centre of Ashington. The home is close to the shopping facilities and other local amenities typical of a town centre. The gardens are landscaped and accessible to service users. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first annual unannounced inspection visit. Time was spent talking to the homes registered manager; examining service users care records and the homes policies and procedures. Time was spent talking to the service users and staff, and a tour of the building was conducted. What the service does well: What has improved since the last inspection? A high percentage of staff has continued to achieve NVQ training. The staff team have commenced “Memory Lane” training this is part of life for the moment concept, and also specialist dementia care training. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 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. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 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 Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 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 2 3 4 The homes admission procedures are robust ensuring that the people moving into the home are appropriately placed. The homes statement of purpose is available in large print however; it is recommended that information should be available in a range of formats such as video or audiotape. EVIDENCE: Details of the extra charges and what these are for, are in the contract given to service users and are agreed prior to their admission. The homes Statement of Purpose and the Service Users Guide both contained the full range of information required. Four service users interviewed confirmed they had been given copies of the guide. These should be made available in a range of formats eg on audiotape or video. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 9 The inspector saw a copy of the standard contract used. It contained the range of information required by the standards. Three service users interviewed confirmed they had a copy of their individual contract. Three service users’ files were checked and on each were a copy of a full needs assessment. These were carried out by the referring social worker and for those self-funding by the registered manager. They contained appropriate information, and those service users interviewed confirmed they were involved in drawing up both these initial assessments and the home’s subsequent service user plans. The 3 service user plans checked by the inspector were comprehensive, and listed details of service user’s needs and actions taken by the staff to meet these needs. “See standard 7 for additional information”. All those residents interviewed said their needs were met and they were happy with the care offered to them. Three care plans were checked and staff members interviewed. These confirmed that a range of specialist services was provided to service users. The staff interviewed were helpful and informative about the needs of the service users, they had a range of appropriate and relevant training and experience. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 9 10 11 The home ensures that the health care needs of the service users are met; all have access to a range of health care professionals. The service users social care plans need to be more descriptive, these should include details of each individual’s social interests. Care plan evaluations must be completed monthly or more frequently if necessary. Service users or their representatives should sign agreed risk assessments. EVIDENCE: There is evidence of a comprehensive assessment in the service users’ care plans. There is also a comprehensive risk assessment of service users, however these should be agreed and signed by service users or their representatives Each service user has an allocated key worker. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 11 Care plans are drawn up with service users. There is evidence that plans are amended and reviewed on a regular basis, one of the care plans evaluations had not been completed since February, the manager agreed to address this immediately. In order to fully meet the service users social needs, care plans need to be more specific by describing each individual’s interests and hobbies. The inspector was informed that self-advocacy is promoted and any rights that are restricted are linked to risk assessments. Each service user receives support from staff to manage their finances. Service users’ all indicated that they are able to make decisions for themselves, they said that staff treated them with respect at all times, without exception all spoke highly of the care that they received. The homes medication systems are well managed and staff had received accredited medication training. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 13 14 15 Social activities are well organised, creative and provide stimulation and interest, additional staff on the DE unit will enhance the social lives of the service users. Six monthly review meetings must take place for all service users, including those whom are self funding. Nutritional assessments must be introduced to maintain, and monitor appetite and nutrition. EVIDENCE: Each service user has a social assessment carried out and this information needs to be transferred onto their individual social care plans. All service users relatives are invited to attend review meetings, however it is essential that 6 monthly review meetings be held for all service users including those who are self-funding. There was evidence that service users have access to a range of activities within the local community e.g. shopping, pub outings, theatre trips etc. The home also employs an activities co-ordinator. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 13 The service users said that they are able to choose who they want to see and when. There was evidence that daily routines promote independence, choice and freedom of movement. Meaningful orientation notice boards were seen to be in place on the DE unit. The staff were observed interacting in a sensitive and respectful manner with service users. The Home’s menus are based on the general likes and dislikes of the service users. At least two hot meals are provided on a daily basis. The menus appeared to be varied and nutritional and all are offered a choice at meal times. The service users said that the food was very good, and they confirmed that they are always provided with a choice. The inspector discussed the use of nutritional assessments with the manager; these will need to be introduced for all service users. A range of special diets can be catered for. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 17 18 Complaints are well managed and provide service users with confidence that their concerns will be listened to, taken seriously and acted upon. Appropriate vulnerable adult procedures were in place, and POVA training is on going for all staff. EVIDENCE: The home does have a complaints procedure; it contains details of how to contact the CSCI to make a complaint that complaints would be responded to in 48 hours. Two service users interviewed confirmed that they had been given copies of the procedure and that staff listened to their complaints and dealt with them fairly. Two service users spoken to who had previously made a complaint said these had been dealt with fairly. The home does keep a record of complaints. The home has a Whistle Blowing policy procedure as well as, the Local Authorities Vulnerable Adults procedures. The home also has a copy of the D.H. “NO SECRETS” for further information. The Home maintains detailed financial records on behalf of the service users; There was evidence of personal spending and receipts are kept. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 20 21 22 23 24 25 26 All areas of the home are well decorated and maintained to a good standard. The environment provides safe and comfortable surroundings in which to live. EVIDENCE: On the day of the inspection the home was clean, well decorated and well maintained. The service users interviewed did say it was homely and comfortable. The grounds were tidy, safe, attractive and accessible. The fire service and the environmental health department had made visits to the home. Requirement made by these organisations had been actioned. There are sufficient rooms for a variety of activities to take place. Service users said that they could see visitors in private in their own rooms. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 16 The dining areas are large enough to cater for all service users. There is a designated smoking lounge. Outdoor space and all areas of the home are accessible to people in Wheelchairs. Furnishings and fittings were domestic in design and in good condition. The home does have a sufficient number of baths, showers and toilets. Doors were labelled and had privacy locks. There were appropriate aids and adaptations – eg seat raisers, grip rails, bath hoists. Room dimensions were such there was space on either side of the bed when necessary to enable access for carers and specialist equipment. Service users’ bedrooms checked all had opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. Radiators were low surface temperature and pipes were guarded. All rooms had en-suite facilities. There was emergency lighting throughout the home. Valves are in situ at water outlets to ensure water is provided close to 43°C to prevent scalding. The home was clean and free from offensive odours. The laundry facilities appeared to be well organised, COSHH information was displayed. Washing machines have the specified programme to meet disinfection standards. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 28 29 The deployment and number of staff available on the DE unit is not sufficient to meet the holistic needs of the service users. The procedures for the recruitment of staff are robust and offer protection for the people living in the home. EVIDENCE: Staff levels on the day of the inspection did meet the agreed level established when the home was first registered. Samples of 4 weeks’ rotas were checked and these stated the required numbers of staff were on duty. The inspector observed that the service users on the DE unit require a great deal of support and supervision. The staff on this unit were observed to be very caring and attentive however, they were also exremely busy trying to meet the holistic needs of all the service users. Three service users with high dependency needs require the assistance of two staff at all times. The inspector recommends that additional staff are needed on this, this will ensure that they are able to meet the collective personal, social and health care needs of the 16 service users. It is recommended that the staffing levels on this unit are increased from two staff to three across the working day. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 18 Current staffing levels are; Down-stairs unit, 27 service users, 1 senior 2 care staff. Residential unit first floor; 17 service users, 1 senior 1 care staff. DE unit 16 service users, 2 care staff with support from the senior from the residential unit on the first floor. All the staff were over 18 years of age and those left in charge were at least 21. The inspector checked staff records and found that 75 of the home’s staff is expected to qualify to NVQ level 2/3 by December 2005. This is good practice. Staff files were checked. The home has a thorough recruitment process which includes obtaining two written references, obtaining full employment histories and checking gaps in these, a criminal records check, medical checks, obtaining proof of ID and of any qualifications. Staff confirmed these processes occurred and that they received job descriptions and statements of terms and conditions. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 31 32 33 35 37 38 The home is well managed, providing guidance and direction to staff to ensure service users needs are consistently met. There are procedures in place that promote and safeguard the health, safety and welfare of the service users. As part of the homes Q/A system, relatives and professionals views of the home should be sought. EVIDENCE: The registered manager has many years experience in senior management and is working towards a level 4 National Vocational Qualification in management and care by 31.12.05. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 20 In the last year all of the staff team have attended several courses to keep themselves up to date. Staff interviewed were clear about the their responsibilities. Staff interviewed spoke positively about the manager saying she had encouraged both staff and service users to contribute to the development of the service. The home does have a quality assurance system, which seeks the views of service users, via meetings and questionnaires. The home has produced an annual development plan. The manager has agreed to seek the views of the home by consulting relatives, GP’s, District Nurses, volunteers, advocates and social workers, all will be sent questionnaires. The results will be incorporated into the annual development plan. Service users are informed when inspections take place and have access to inspection reports. Copies are on display for relatives/others to see. The records inspected were found to be appropriately completed, these included the fire log book, accident book, personal allowance records, Health and Safey manual. Appropriate maintenance contracts for the home are in place. Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 2 x 3 x 3 3 Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 22 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 OP 7 Regulation 15 Requirement Implement detailed social care plans for all service users. Ensure that all care plan evaluations are completed within the stated time-scales. Regular reveiws must take place for all service users. Agreed risk assessments to be signed by service users or their representatives. Nutritional assessments to be completed for all service users. Increase the staffing levels on the DE unit. Timescale for action 1.11.05 2. 3. 4. OP 7 OP 15 OP 27 15 16 18 1.11.05 1.12.05 31.10.05 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. 2. 3. Refer to Standard OP 33 OP 31 op 1 Good Practice Recommendations As part of the homes Q/A system seek the veiws of the home from relatives and professionals The manager to obtain the registered managers award by 31.12.05 Provide the homes statement of purpose in a range of formats. B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 23 Woodhorn Park Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 Woodhorn Park B53-B03 S55019 Woodhorn Park V241072 120905 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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