Inspection on 19/09/06 for Woodland

This inspection was carried out on 19th September 2006.

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

Woodland 15/09/08

Woodland 23/11/05

Woodland 08/06/05

Woodland 07/01/05

Woodland 25/05/04

Woodland 15/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Maple Lodge

Polesworth Group 32 Station Road

Heathlands

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

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

CARE HOMES FOR OLDER PEOPLE Woodland Trefonen Road Morda Oswestry Shropshire SY10 9NX Lead Inspector Janet Oxley Key Unannounced Inspection 19th September 2006 10:00 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 Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Address Trefonen Road Morda Oswestry Shropshire SY10 9NX 01691 656963 01691 671225 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) Mr Steven Bol Mrs Catherine Leslie Heathcote Care Home 20 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (19) of places Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 Brief Description of the Service: Woodland is a privately owned care home that provides personal care and accommodation for up to 19 elderly people and one person with a learning disability. The proprietor of the home is Mr S Bol and the registered manager is Mrs C Heathcote who is fully qualified with many years experience and is responsible for the day-to-day running of the home. Mr Bol lives on site on the first floor of the home- the service users’ individual and communal rooms are all on the ground floor with level access throughout. The home is situated in the village of Morda, close to Oswestry. The home’s location is in a quiet residential, rural location with pleasant gardens. The nearby shop and pub are within walking distance. The original part of the building and the purpose built extension are joined by the communal lounges and a conservatory and people choose where they spend their time. The home is generally comfortable and welcoming with a well - established staff group. The home makes their services known to prospective service users in The Statement of Purpose and Service User Guide. The inspection report is mentioned in these documents and is given out on request. Fees are reviewed annually and range from £320 - £340. The only additional charges to service users are for hairdressing and newspapers. This is clearly laid out in the terms and conditions. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, looking at relevant records pertaining to key standards, chats with residents, discussions with the staff on duty and the hairdresser, discussion with the Manager, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports and observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? The main corridor has been redecorated and refurbished and 2 of the bedrooms have been redecorated and recarpeted. It was apparent that the Manager is constantly reviewing all aspects of the service to achieve best practice and a good level of care and quality of life for the residents. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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 Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures that are in place, and have been professionally followed, ensure that the home undertakes all necessary assessments for successful and satisfactory admissions to take place. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide, which includes all the required information for prospective residents. Documentation examined indicated that individuals have a full and comprehensive assessment of their needs prior to admission, which is reviewed and amended as requirements change. Particular attention is given during these assessments, not only to the needs of the prospective service user, but also of the likely effects of his/her admission will have on the existing group of residents. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 9 Significant time and effort is spent making each admission to the home personal and effective and family members and the prospective service user may visit the home as often as they wish until a decision is made. Observations, inspection of records, discussions with the Manager and staff on duty indicated that the home meets the individual needs of the elderly people living at the home in a professional and sensitive manner. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal needs of service users are well met with evidence of regular review and of good multi disciplinary working taking place on a regular basis. EVIDENCE: Personal and healthcare support in this home is offered in such a way as to promote and protect service users’ dignity and privacy in their daily life and at the end of life. Those more frail residents seen, that were being cared for in bed, looked extremely well looked after and comfortable. It was evident during the inspection from looking at records, inspecting the facilities and chatting to staff and residents that individual health, personal and social care needs were being met. Residents were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. The home continues Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 11 to work hard to ensure individual rights are upheld. All residents appeared content and well looked after and those spoken to were extremely complimentary regarding the quality of their life at the home. Visiting health professionals continue to praise the management and care standards there. The storage, administration and the recording of medication appeared to be generally satisfactory. The Manager and her Deputy have received accredited training in the administering of medication and have cascaded the information to senior staff who also administer the medication. It will be necessary however for all staff to have received accredited training to comply with laid sown requirements. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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 the following standard(s): All Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living at Woodland are very flexible and each resident finds the lifestyle experienced in the home meets their individual needs. A number of activities take place, there is an open visiting policy and the menu offers a choice of well balanced and wholesome meals. EVIDENCE: Individual needs, likes and dislikes are clearly shown in the care plans. There was much evidence to indicate that individual rights are fully promoted and residents are certainly enabled to exercise choice and control over their own lives as far as they are able, personalise their own rooms and use them as private places. – eg 3 residents attend a day centre, others go out regularly with relatives and there was evidence to indicate that each resident, who is able, is involved in daily matters around the home. A number of activities, within the home and outside, take place to suit individual needs and tastes and these are fully discussed with the residents and are recorded and monitored. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 13 Visitors are always made welcome, are included in events and are given all the necessary information on aspects of the home and the welfare of the residents. Visitors spoken to have always been complimentary regarding the quality of life for the residents at the home. The menu, meal seen and tasted, discussions with residents, staff and cook and a visit to the kitchen indicated an satisfactory diet in pleasant surroundings with sensitive and respectful help from staff. Kitchen and care staff have all undertaken relevant training. All meals are home cooked and many fresh fruit and vegetables are used. At the time of the most recent Environmental Health Officers inspection matters were generally satisfactory. A recommendation was made to install new flooring in the kitchen which is now in need of total refurbishment. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and professionally and robust procedures and practices are in place to ensure that individuals are protected from abuse. EVIDENCE: The home has a clear complaints procedure, which is given to residents and their relatives before they move into the home. No complaints have been received by the home or CSCI since the last inspection. Minor concerns, received by staff at the home, from or on behalf of residents, are dealt with in a professional manner without delay. It was evident that all staff respect, observe and listen to the residents. The home has all necessary documentation in relation to the protection of vulnerable adults and this subject is included in staff training. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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 the following standard(s): 19, 20, 23 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home provides residents with a warm, safe and homely place to live however it was identified and fully acknowledged that a number of improvements need to be made without undue delay. EVIDENCE: The location and layout of the home are suitable for elderly residents. Communal rooms are well equipped and are warm, homely and welcoming. Bedrooms are personalised and suit individual needs and the gardens and grounds are generally well maintained and accessible to residents and their visitors. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 16 At the time of the most recent Fire Officer and Environmental Health Officer’s inspections matters were reported to be satisfactory. Recommendations made have been complied with however the kitchen and laundry remain in need of refurbishment. It was identified that a number of areas of the home will need refurbishment, repair and redecoration in the near future and a full programme and plan for routine maintenance and renewal of the fabric and redecoration of the premises must be produced, without undue delay, and this must be implemented within timescales agreed. At the time of this inspection the standard of hygiene and cleanliness were generally satisfactory and staff have received training in infection control. Sluicing facilities will need to be considered for improvement in the future. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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 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): All Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a well trained and committed staff group who are meeting the needs of each individual in a sensitive and professional manner. EVIDENCE: Recruitment at the home is thorough and all elements required by Schedule 2 of the Care Home Regulations are maintained on file. The Proprietor and Manager are vigilant in their efforts to ensure that suitable staff are employed to care for the service users. The files of 2 staff recruited in the last year were seen to be satisfactory. Staff turnover is very low and no agency staff are used. All staff spoken to were very complimentary regarding the support they receive and the management of the home. The arrangements for ongoing training and foundation training are good with staff completing this within the first six months. The home continues to support staff to undertake their NVQ awards, more than 70 of staff have achieved NVQ level 2, a very good variety of other training has been undertaken and staff on duty indicated that they were sensitive to the service users needs and disabilities and that their attitudes and practice were monitored and supervised by the manager. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 18 Staff supervision, staff meetings and appraisals are undertaken in a professional manner and training records are maintained for each staff member. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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 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, 33, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear lines of accountability within the homes management structure and the management approach creates an open and positive atmosphere from which the residents benefit. The home has reviewed all aspects of its performance through a programme of self review, questionnaires and consultations and meets the requirements of the Fire Officer and Environmental Health Officer, promoting the health, safety and welfare of the residents. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 20 EVIDENCE: The registered manager is a State Registered Nurse and has completed the Registered Managers Award. She has many years experience and carries out her responsibilities with sound leadership skills promoting a professional ethos within the home. Her Deputy has also completed NVQ 4 and the Registered Managers Award. The manager involves herself fully in the day-to-day running of the home and can fully relate to matters pertaining to the National Minimum Standards. The manner in which the manager and staff responded to this inspection indicated that a sound management approach is in place and that she is committed to achieving best practice and to developing equal opportunities. Equality and diversity for the service users were seen to be promoted throughout the home, within the assessments, care plans and activities. Equality for staff is promoted through increased opportunities for training at all levels. Quality assurance systems are in place and results of service user surveys are published. There was evidence available to indicate the manager ensures, so far as is reasonably practical, the health, safety and welfare of service users and staff. All staff have attended a health and safety course and relevant mandatory training was reported to be up to date or booked. It was reported that a first aider is on site at all times and accident records are satisfactorily maintained and audited by the Manager. Woodland DS0000020692.V297097.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 x x 3 x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 22 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 That all staff administering medication receive accredited training on the subject. That a programme and plan of routine maintenance and renewal of the fabric and decoration of the premises be produced and be implemented within stated timescales and records kept. The laundry floor must have an impermeable, readily cleanable finish. This requirement has previously been made and must be complied with to avoid further action being taken. That the kitchen be refurbished. Timescale for action 31/12/06 2 OP19 23(2) 31/10/06 2. OP26 23 31/12/06 3. OP19 16(2)(g) 31/12/06 Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 23 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 Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Woodland DS0000020692.V297097.R01.S.doc Version 5.2 Page 25 - 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!