Inspection on 29/06/05 for Woodland Manor

This inspection was carried out on 29th June 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 Manor 06/08/08

Woodland Manor 25/09/07

Woodland Manor 03/10/06

Woodland Manor 08/12/05

Woodland Manor 11/03/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Golden Days Golden Days Retirement Home Whitton Park, Thurleston Lane Ipswich, Suffolk IP1 6TJ Lead Inspector Claire Hutton Unannounced 29 June 2005 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. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Golden Days Address Whitton Park, Thurleston Lane, Ipswich, Suffolk, IP1 6TJ 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) 01473 461622 01702 713207 None provided Anchor Trust Mr Graham Garrod CRH (Care Home) 36 Category(ies) of OP (Old Age) 36 registration, with number of places Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person must forward a revised Service User Guide to the Commission for Social Care Inspection within one month of Registration. 2. The Provider must address the issues raised in correspondence dated 28th July 2004 from CSCI, Suffolk Office. 3. The Responsible Person must attend an office of CSCI to obtain a Criminal Records Bureau Disclosure within six weeks of the date of registration. 4. The home may accommodate persons of either sex, over the age of 65 years, who require care by reason of old age. 5. The maximum number to be accommodated must not exceed 36. This conditions will revised upon issuing a new certificate in the coming months. Date of last inspection 11th March 2005 Brief Description of the Service: Golden Days is situated within Whitton Park and is set in extensive grounds. There is adequate parking to the front and the nearest public bus stop is a walk from the home. The building is a large Victorian House, which has been extended to incorporate a three-storey block comprising two floors care home accommodation. The ground floor of this block comprised a mixture of care home bedrooms and a private occupied flat that was not part of the registered premises. The accommodation comprises of 32 single rooms and 2 double rooms. Four single bedrooms were reported in the Statement of Purpose to be under 10m². There is also a large lounge with dining room adjoining. There is also a further lounge/dining area near to the kitchen in the main house and two smaller quiet lounges in the extension. The Home offers accommodation in the category of elderly people who require personal care. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.5 hours on a mid week afternoon in June. During the inspection 4 staff were spoken with, this included the designated senior in charge and the administration support for the home. Some discussions were in private. 4 residents were met and discussions had, this included residents whose records and care was tracked. Records inspected included all care records for two residents, the roters, evidence of staff training, the record of complaints and the homes recruitment procedure. The CSCI have received an application for the home to accommodate two named individuals, one person with a learning disability and one person with dementia. Both these individuals are currently resident at the home. The CSCI is processing this application. Two new bedrooms are due to be available soon and were inspected by the CSCI on 13th June 2005. This will not increase the registered numbers as two rooms have been decommissioned. What the service does well: What has improved since the last inspection? Several environmental changes have either happened or are planned shortly. Two new large bed-sitting rooms are very near completion. The lounge area has new curtains, new large TV and is awaiting a new carpet that will cover the lounge, dining area and entrance. The two decommissioned bedrooms will to used to accommodate the duty office and administration assistance. This is Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 6 close to the communal areas and front door. This will free up the small dining room, so that it can go back to being used by the residents. Four of the seven requirements made at the last inspection has been actioned. A positive contact had been made with the local falls prevention officer. Risk assessments for the stair lift were in place for those residents who needed it. The fire officer had recently visited and given advice. Five staff had updates on manual handling training and another session is planned. 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. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 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 Golden Days v236820 i54-i04 s60707 golden days v236820 050628 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 and 3. 6 does not apply People who use this service can expect the home to know enough about them to meet their care needs, but may not receive prompt attention to their contract and terms and conditions. EVIDENCE: Two peoples records examined had both moved in the week before. Neither of these people had a contract or terms and conditions of residence in their records, but the administration assistant was able to explain the situation regarding these two individuals, as further information was needed from the local authority. A requirement was made at the inspection in December 2004 for all residents to be issued with a contract and terms and conditions of their residence, at the last inspection in March this had progressed and was due to be completed. At this inspection this work had not been completed. The assessment information obtained before the last two people were admitted to the home was examined. In both cases this included information from the Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 9 assessor in the local social services. This was also supplemented by information from the hospital. It is good practice for the home to visit prospective individuals and make their own assessment. This was done in both these cases. However, the information gathered by the acting manager was not comprehensive and lacked detail. It was not dated or signed. One resident spoken with said they had looked at three homes before they came to find Golden days. They chose this home as they, including the family, believed it would meet their needs. They especially liked the environment, the friendly staff and approach of the acting manager. The CSCI has a combined document know as the Statement of Purpose and Service Users Guide. This document was required as part of the registration of this home. This document was seen as an interim measure. The organisation with the acting manager is working on an improved version that will take into account the development of rooms and a variation of the conditions that will allow the home to continue to care for one individual with a learning disability and one person with dementia already resident at the home. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 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) 7,8 and10 Residents can expect that their health will be monitored and appropriate health professionals consulted when required. They can also expect personal care to be given promptly and with due respect and privacy. EVIDENCE: Two care plans were examined, these were developed from the assessments provided to the home. The two senior staff explained it was there job to complete the plan of care and they did this from the assessment, but also by meeting with the individual resident and going through the plan with them. The newest care plans did not have a photograph of the residents on them. Each resident is registered with a local GP. It was explained that when a resident moves to the home they may have to change their GP if that GP will not travel to the home, but if possible they do remain with their own GP. One resident said that if you feel unwell then all you need do is tell the senior on duty and they will arrange for the GP to visit you, but more often that not the seniors know that your not well and will call them in. A District Nurse was visiting and had come to do dressings for two residents. A telephone call was received from the District Nurse to ensure all was OK with a newly prescribed Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 11 continence aid for one resident. One resident had been assessed for a new hearing aid and was awaiting for this to arrive. Staff were observed to care for residents and were friendly and respectful. Staff knew individuals well and varied their interactions accordingly. Personal care was given in private and discreetly. One resident said that nothing is too much trouble and the staff will always help you out. Another resident said that staff always come promptly when you ring the bell. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 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 and 15 Sufficient activities and flexible catering are on offer for individuals to truly choose their preferred lifestyle within Golden days. EVIDENCE: As you walk into the front porch of the home there always tends to be a social event advertised on the wall. This has a friendly encouragement to friends and relatives to join in. On the notice board near the lounge there are more details of events such as exercise classes, bingo, card games and recently container pot planting. These colourful containers were seen newly planted near the conservatory. Staff spoke of recent events such as the cheese and wine, strawberry tea and the Otley bell ringers and a choir visiting. The residents spoke of the fish and chip supper they enjoyed as it was eaten out of the paper if they wanted. One person particularly enjoyed the bingo. The menus were on display in the hall for everyone to view. This showed that a balanced varied diet was on offer. Residents spoken with all praised the food and liked the choice available to them, saying it was hot and plenty of it. The inspector has previously eaten at the home and found the food tasty. Drinks were given out from a trolley at set times, but residents were also seen to request hot drinks and these were promptly brought. One relative was briefly spoken with and they were very happy with the home. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 13 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 and 18 People who use this service will find that any complaint they make will be taken seriously and dealt with. Protection from abuse is taken seriously, but further staff training further enhance this. EVIDENCE: Anchor have a complaints leaflet available in the porch as people enter the home. This is also in the terms and conditions given to residents and the Statement of Purpose and Service Users Guide. The record of complaints was examined and found to be up to date. The recruitment of staff included the consultation of the national POVA (Protection of Vulnerable Adults) list and evidence was seen on staff files. A requirement was made at the last inspection to ensure all staff are aware and trained in the procedure s to be followed for the protection of vulnerable adults. From discussions with staff this training had not yet taken place, but the administration assistant said it was going to be organised. No evidence of this training was seen on to training plans examined. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 14 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 and 26 People who use this service will find the environment comfortable and generally meets the needs of older people however, the communal space occupied by residents needs to be further increased as planned. EVIDENCE: A tour of the communal areas was undertaken and private rooms were seen. The home was clean and free from any odour. The accommodation comprises of 32 single rooms and 2 double rooms. Rooms have varied additional facilities including en suites, balconies and kitchenettes. One resident spoken with was very happy with the room they occupied, as they was able to have a pet and had plans to make the balcony pretty with tubs of flowers and a chair. The home offers a large conservatory area with the main sitting room and a dining room adjoining. The lounge area has new curtains, new large TV and is awaiting a new carpet that will cover the lounge, dining area and entrance. The lounge/conservatory was rather warm and the remote control blinds had Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 15 been fixed that day and small fans with temperatures displayed had been purchased. There are two toilets close to the entrance and communal areas. The home currently has 7 bathrooms 6 of which had aids and adaptations for assisted bathing. Several adaptations to the building have taken place to ensure access and ease of use by older people. The home had two shaft lifts. Due to age one has been decommissioned. The other shaft lift was in full working order during the inspection and was used by the Inspector. The home has two stair lifts. At the previous inspection there were two matters raised around the environment. Firstly around fire precautions. The acting manager has had the fire service visit and has acted upon there advice. Secondly, it was recommended that the home renumber the rooms in order to lessen confusion with the letters and numbers currently in use. This has yet to be actioned. The amount of communal space was only adequate at this inspection due to there only being 27 people resident. If the home were at full capacity then there would not be sufficient space to accommodate people to sit and dine. The designated communal space includes the small dining room close to the kitchen. It is planned for this to be returned to the residents for their use once the decommissioned bedroom along the same corridor is made ready for the duty office and administration support. This work must be promptly attended to. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 16 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) 27,29 and 30 People who use this service can expect to have enough staff who are appropriately recruited and well trained, however the home currently cannot assure residents of consistent care staff. EVIDENCE: All roters of staff working at the home were inspected this included senior staff, care staff, housekeeping and maintenance, but no roter was available for kitchen staff. A member of kitchen staff was able to produce her own personal roter. There were sufficient staff in the supporting roles of kitchen, housekeeping, maintenance and administration. The senior staff roter showed that there was always a senior carer on shift and the night roter was adequately covered. There were however a high number of care shifts covered by agency staff. In the month of June and up to 10th July there were 33 shifts covered by agency. This was especially high over two weekends. This placed undue stress on senior carers. Residents spoken with said they were not too happy with the unfamiliar faces and things were slower, but they were cared for adequately. In relation to two new residents one person did not have there inventory of valuable possessions completed and another person did not have their risk assessment completed in relation to fall prevention. These were things that perhaps a regular member of staff may not have forgotten to do. The recruitment records for two new members of staff were examined. All the appropriate records and checks were in place. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 17 The record of staff training was examined. The administration assistant explained that the acting manager was in the process of collating this information in a better format. Records for one carer and one senior were examined and this showed all the base line training expected such as fire training, back care, health and safety, first aid and basic food hygiene. With the senior having medication training and NVQ 3. Five staff had recently updated their manual handling training, evidence was seen and a further training day is planned for the other staff who could not make the day. This was possible because the home have two staff trained to train staff in manual handling. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 18 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 Golden days is adequately managed but would benefit from the positions of manager and deputy resolved and a period of stability in senior management. EVIDENCE: Anchor had newly acquired this home at the end of last year. The registered manager of this home has been absent for 8 months. In that time Ms Lesley Tournay-Godfrey has acted up from her role as deputy manager. Also, in that time four different area managers within Anchor have supported her. The acting manager was unavailable for this unannounced inspection, however staff and residents spoke very highly of her and of the hard work she has undertaken. Ms Tournay-Godfrey had previous experience in the care of elderly as a deputy manager in another care home. She holds the diploma in Management and Care Services level 4 and an Assessors Award in NVQ. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 19 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 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 3 3 x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 x x x x x x Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 20 yes 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 1 Regulation 4&5 Requirement A revised Statement of Purpose and Service Users Guide is required to take into account the changes at the home. A contract, with terms and conditions must be in place and agreed with every resident or their representative. (This is a repeat requirement from 17/12/05 and 11/03/05) All staff must be aware and trained in the protection of vulnerable adults. (This is a repeat requirement from17/12/05 and 11/03/05) The designated communal space of the additional dining room/lounge must be put back as residents use. Residents needs must be met at all times therfore: - the skill mix of agency and permanent staff must be kept to a minimum. The use of agency staff should never outwiegh the use of permanent staff in any one shift. i.e no more that 50 agency staff. Timescale for action 08/08/05 2. 2 5(1) 28/06/05 3. 18 13(6) 28/06/05 4. 20 28/06/05 5. 27 18(1a&b) 28/06/05 Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 21 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 3 19 27 Good Practice Recommendations Information gathered by the homes representative should be accurate, comprehensive, signed and dated. All the bedrooms should be numbered in sequence (This is a repeat recommendation from 11/03/05) The roter for kitchen staff should be available for inspection. Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection St Vincent House Cutler Street Ipswich, Suffolk IP1 1UQ 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 Golden Days v236820 i54-i04 s60707 golden days v236820 050628 stage 4.doc Version 1.40 Page 23 - 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!