Inspection on 26/01/06 for Woodland Grove

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Grove 16/05/07

Woodland Grove 29/11/06

Woodland Grove 08/08/05

Woodland Grove 30/03/05

Woodland Grove 16/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodland Grove Weston Park Bath Bath & N E Somerset BA1 4AS Lead Inspector Jon Clarke Unannounced Inspection 26th January 2006 09:30 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 Grove DS0000008163.V278443.R01.S.doc Version 5.1 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 Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodland Grove Address Weston Park Bath Bath & N E Somerset BA1 4AS 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) 01225 464004 philip.caple@anchor.org.uk Anchor Trust Mr Philip John Caple Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 42 persons aged 65 years and over requiring personal care only 8th August 2005 Date of last inspection Brief Description of the Service: Woodland Grove is a care home for older people owned and managed by Anchor Trust Foundation and provides accommodation for up to 42 residents. The home is a converted older property, which has been extended and adapted to provide residential care within individual flats. Each flat has a bed sitting room, small integrated kitchen and en-suite bath or shower, basin and toilet. There is a large communal lounge, which can be divided into two rooms and a dining room with direct access to the patio seating area. There is lift access to all parts of the home. The home is set in extensive gardens and located in the Weston area of Bath within easy reach of the town centre and local amenities. Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day; the manager was present during this inspection. As part of the inspection a number of documents were looked at including care plans, training records and records relating to health & safety. There was also an opportunity to discuss with a number of resident their views of living in Woodland Grove. A focus of this inspection was the completion of care plans which had been an area identified at the previous inspection which required improvement. What the service does well: What has improved since the last inspection? What they could do better: Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 6 There remains poor practice around care planning and evidence of good practice in this area is limited with significant gaps in the recording of care needs. There were gaps in daily records which should provide an ongoing picture of the care provided to individual residents and highlight changes in their physical or mental health. This information contributes to effective care panning and ensuring that care needs are as far as possible met. There was a real sense that the morale of staff is low following a number of staff changes and vacancies which has placed pressure on existing staff. 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 Grove DS0000008163.V278443.R01.S.doc Version 5.1 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 Grove DS0000008163.V278443.R01.S.doc Version 5.1 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): Standard 3 was looked at on the previous inspection and the standard was met. EVIDENCE: Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 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): 7,8 There is a failure to complete care plans and associated records in a way that helps ensure that health and social care needs are being met and as a consequence residents are potentially at risk. EVIDENCE: A number of care plans (7) were looked at and illustrated significant gaps in their completion. Risk assessments had not been reviewed and in one instance where individual was self-medicating no risk assessment had been completed. Resident who was insulin dependant had no risk assessment or guidance about the safe management of their diabetes. Inconsistent information about care needs: resident admitted 2/11/05 had no information recorded about their daily living routines, dietary/nutritional needs, current medication being prescribed, social needs. There was lack of reviewing of care plans on a regular basis. Mobility and Moving & Handling assessments not completed (1) or reviews undertaken. (2). Daily records not completed: since 29/10/05, others 13/09/05, 2/08/05. Heath care needs are met through the provision of community health services including district nurse support for residents who have ongoing medical needs Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 10 such as management of diabetes. Residents are able to retain their GP if they are continuing to live in GP catchment area. Chiropody, optician and dental treatment are provided on regular basis. Whilst the home has links with mental health services records of one resident showed that their mental health has changed however there was no formal assessment of their mental health. This would possibly provide a diagnosis and assist staff in meeting their mental health needs. The individuals care plan failed to show how her care needs had changed or indicate the most effective way of managing their “restless” behaviour. This was highlighted in records, which stated that when asked by a member of staff to “refrain from picking up debris ? in the garden became aggressive” however a note on her social interests said that she had been a “keen gardener”. Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 11 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): 12,13 The home provides opportunities for social activities and residents maintain contact with family, friends and the local community wherever possible. EVIDENCE: Residents confirmed that there are “enough activities” available in the home to include quizzes, games and outside entertainers. Outings are also arranged particularly during the summer months. Church services are held in the home. If residents attended local clubs they are encouraged to continue attending if able to do so. The home recognised the importance of keeping links with family and friends and efforts are made to make sure visitors are made to feel welcome in the home. One visitor spoken with on this inspection said how they “always feel welcomed” when visiting the home. Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has an effective complaint procedure and residents feel their views will be listened to and acted on. EVIDENCE: The complaints procedure is set out in the Statement of Purpose and residents spoken with were aware of their ability to complain or register any dissatisfaction. One residents said they “would not hesitate in saying” if they were unhappy about anything. Another said they felt “staff listened to what we have to say” “they would do something if I said” again this was about telling staff or the officer staff if they were concerned or “worried about anything” There have been 2 complaints since the previous inspection both were investigated appropriately and as a result areas for improvement were identified. Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home provides a clean and pleasant environment for residents. EVIDENCE: In looking around the home it was evident that the home has good practice in maintaining the home and on the day of the inspection was clean and free from offensive odours. There are procedure in place to make sure practices help to provide a hygienic environment and reduce the risk of infections through safe working practice including use of protective clothing when necessary. Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 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): 27,30 Staffing arrangements are good so that residents receive the necessary care. The training of staff helps in making sure that staff are competent and knowledgeable in providing care for older people. EVIDENCE: Staffing rotas were seen for last month. They showed adequate staffing being on duty: 4 am 8-3, 3 pm 3-10 and waking night staff. However vacancies have created pressure and use of agency staff presents difficulties for permanent staff. Wherever possible agency staff are chosen who have worked in the home previously. Efforts have been made to recruit permanent staff but this has been difficult. The use of agency staff should be avoided wherever possible in that this can threaten continuity of care for residents. However it is recognised that on occasions there is no other option and staffing levels must be maintained at all times to ensure the care needs of residents are met in an efficient manner. Training records were seen for a number of staff (8). They showed and evidenced that staff receive the mandatory areas of training ie moving & handling, fire safety, first aid and food hygiene where necessary. In addition staff have received training in Mental Health/Depression, Dying with Dignity. It would benefit staff (and this was confirmed by a member of staff) if training could be provided around working with individuals who have diabetes this could perhaps be provided by district nurse. Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 15 In talking with a new member of staff they confirmed that they had received the necessary training and importantly with regard to moving and handling would not be expected to undertake any care tasks, which placed her or others at risk until they had undertaken this training. They also spoke positively of their induction period and support received from other members of staff which included shadowing members of staff. Residents spoke positively of the support they receive from staff “always around when you want them” “can’t fault them” “very caring” “all very good”. Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 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): 38 The health & safety of residents and staff is protected as far as possible by the procedures and practices of the home. EVIDENCE: Records showed good practice in maintenance and checking of fire equipment. Weekly checks of fire alarms and emergency lighting. Service of fire equipment and system takes place annually last 5/05. There is a Fire Risk Assessment which identifies environment risks this had been reviewed 30/09/05. Monthly Health & Safety checks take place around security of the home, fire safety and equipment in the home. There are COSHH risk assessments regarding use of potential harmful chemicals in the home. Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 18 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. 1 Standard OP7 Regulation 15 Requirement Residents Care Plans must be in sufficient detail to provide clear guidance to staff on the tasks to be taken to meet health and welfare needs. Care Plans must be kept under review. Where individuals have responsibility for their medication a risk assessment to be completed and reviewed and regular intervals. Records to be kept as specified under Regulation 17 Moving & Handling assessments to be completed for all residents and reviewed at regular intervals. Timescale for action 30/04/06 2 OP9 13(4)B,C 30/04/06 3 4 OP37 OP7 17 13 (4c,5) 30/04/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP37 Good Practice Recommendations Maintain regular records giving any changes in residents DS0000008163.V278443.R01.S.doc Version 5.1 Page 19 Woodland Grove 2 OP30 circumstances, difficulties in providing care and care given to residents. Provide training to staff around the safe management of individuals who have diabetes. Woodland Grove DS0000008163.V278443.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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