Inspection on 23/11/05 for Woodland

This inspection was carried out on 23rd 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodland 15/09/08

Woodland 19/09/06

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 Karen Powell Unannounced Inspection 23rd November 2005 10:15 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.V268227.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. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 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.V268227.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: Woodland is a privately owned establishment that provides personal care and accommodation for up to 19 elderly people and one person with a learning disability. The homes aims and objectives taken from the homes aims and objectives statement states “To enable each resident to maintain a lifestyle as close as humanly possible to that which he or she is used. To maintain each residents right to self - determination and individuality”. The proprietor of the home is Mr S Bol and there is a registered manager, Mrs C Heathcote, who 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 for people to walk or sit in. 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. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 10.15am and lasted 2 hours and fifteen minutes. All places were occupied. The inspection included discussion with service users, staff and visitors. Observation of daily routines, examination of staff records, service user satisfaction questionnaires and a home tour took place as part of the inspection. The home was well presented and visitors were seen to be welcomed throughout the inspection visit. This inspection reviewed key standards only as the home is currently considered to be performing well and thus warrants the application of a reduced methodology. This report should be read in conjunction with the announced inspection report of 23rd June 2005. What the service does well: What has improved since the last inspection? The home has purchased it’s own hoist since the last inspection to address the needs of those service users requiring hoist transfers living at the home. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 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.V268227.R01.S.doc Version 5.0 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.V268227.R01.S.doc Version 5.0 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): These key standards were assessed at the last inspection of 23rd June 2005. EVIDENCE: Woodland DS0000020692.V268227.R01.S.doc Version 5.0 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 the following standard(s): These key standards were assessed at the last inspection of 23rd June 2005. EVIDENCE: Woodland DS0000020692.V268227.R01.S.doc Version 5.0 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 the following standard(s): 12 Service users are enabled to conduct their lifestyle in the way that suits them best, taking into account their personal preferences. EVIDENCE: The inspector spoke to several service users who were happy to share their experience of living at the home. Service users told the inspector that they are able to choose what they do with their time. One service user regularly walks, weather permitting. One visitor and service user said how they were looking forward to the forthcoming Christmas party, which they had just received an invitation for. Through observations made service users were seen to be reading the daily paper, watching television and another individual was completing the crossword puzzle. Service users told the inspector that they enjoy the hairdresser’s visit who attends each Tuesday. Service users looked comfortable and settled in the home making choices about how they spend their time. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 Page 11 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): These key standards were assessed at the last inspection of 23rd June 2005. EVIDENCE: Woodland DS0000020692.V268227.R01.S.doc Version 5.0 Page 12 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, 24 & 26 Service users live in a safe, well-maintained environment. The home has chosen not to promote service users’ privacy through the provision of locks on individual bedroom doors. EVIDENCE: A tour of the home took place as part of the inspection process. All areas were seen to be well maintained, clean and pleasant throughout. Service users spoken to in regard to the standard of cleanliness told the inspector that they were happy with their individual accommodation. Not all individual bedrooms have locks fitted to the doors and in order to fully respect an individuals right to choose whether they use this facility locks should be in place on all bedroom doors. This is an ongoing requirement from previous inspections. Lockable storage space is not available in all rooms due to the fact that some service users have brought in their own furniture. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 Page 13 The requirement to the laundry floor to make the floor finish impermeable remains outstanding. This is due to the fact that the home may be refurbishing the laundry in the near future as part of the homes future development plans. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 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 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): 29 & 30 The home’s recruitment procedures have not been strictly adhered to at all times. The home continues to support staff in completing training relating to their work role. EVIDENCE: There have been three new recruits to the home since the last inspection. The files of all three were examined to monitor the homes recruitment practice. It was noted that all three employees had commenced employment prior to receipt of a CRB disclosure. The manager stated that all three never worked alone until disclosures were received. The manager was reminded that this should not be common practice and if in exceptional circumstances an individual has been employed before receiving a CRB disclosure then the Department of Health Guidance must be followed along with a completed risk assessment. All staff receive induction training. Checklists of the homes induction lists were seen to be signed off by the manager and the employee. Induction workbooks were not available at the inspection, as individuals had taken records home. Discussion with various members of the staff team informed the inspector that refresher training in moving and handling, fire and evacuation procedures and abuse had all taken place since the last inspection. The manager and one other member of staff have also attended a dementia awareness course. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 Page 15 The home continue to support staff to undertake NVQ training and the manager stated that one member of staff has completed NVQ level 3, three members of staff have completed NVQ level 2, 1 member of staff has completed NVQ level 4 and two staff have just commenced NVQ level 2. An observation of one member of staff completing NVQ training was taking place as the inspector arrived. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 Page 16 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 The home is managed by an experienced, suitably qualified individual who carries out her responsibilities fully. Service users are consulted with regard to their views about the service. EVIDENCE: Mrs Heathcote is a trained nurse. She has continued to build on her knowledge and attends various courses in order to do this. Mrs Heathcote is also an NVQ assessor and is committed to the continued development of her staff team, supporting them with on going training. Service users spoken to gave positive comments about the manager and her commitment to the home. Several commented on her presence within the home and her willingness to address any concerns they may have. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 Page 17 The home continues to seek the views of service users not only in general dayto-day conversation but by means of a service user satisfaction questionnaire. If an individual needs assistance or is unable to do this then families are asked to assist their relative. The last survey was carried out in October 2005 and responses were shown to the inspector, the manager acknowledged she had yet to fully analyse the responses. Those seen were complimentary in all aspects of the running of the home, environment, day-to-day life and service user involvement. Woodland DS0000020692.V268227.R01.S.doc Version 5.0 Page 18 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 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 x 18 x 3 x x x x 1 x 2 STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x x x x Woodland DS0000020692.V268227.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES 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. 2. 3 Standard OP24 OP26 OP29 Regulation 13(5) 23 Schedule 2 19(5)(d) Requirement Suitable locks must be installed on service users doors followed by a risk assessment. The laundry floor must have an impermeable, readily cleanable finish. A CRB disclosure or POVA 1st check followed by a CRB disclosure must be obtained before employing staff Timescale for action 23/02/06 23/02/06 23/01/06 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.V268227.R01.S.doc Version 5.0 Page 20 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.V268227.R01.S.doc Version 5.0 Page 21 - 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. 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