Inspection on 08/12/05 for Woodland Manor

This inspection was carried out on 8th December 2005.

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 Manor 06/08/08

Woodland Manor 25/09/07

Woodland Manor 03/10/06

Woodland Manor 29/06/05

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 Helen Fontaine Announced Inspection 8th December 2005 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 Golden Days DS0000060707.V255916.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. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Golden Days Address Golden Days Retirement Home Whitton Park, Thurleston Lane Ipswich Suffolk IP1 6TJ 01473 461622 01702 713207 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) Anchor Trust Post Vacant Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 One named individual to be accommodated with dementia DE (E) 2 One named individual to be accommodated with learning disability (LD) 11th March 2005 Date of last inspection 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 of care home accommodation. The ground floor of this block comprised a mixture of care home bedrooms and a privately occupied flat that was not part of the registered premises. The accommodation comprises 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 DS0000060707.V255916.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection of Golden Days took place over six hours and was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. Five requirements were set at the previous inspection and the home has complied with all of the required action. The inspector talked to a number of staff and residents, as well as touring the building, visiting residents in their rooms and joining them during the lunchtime. The acting manager assisted the inspector and their support during the inspection was very much appreciated. Ten Service Users’ Comment Cards were completed and returned to the inspector before the inspection. The home also supplied the inspector prior to and during the inspection with, the Service Users’ Guide, Principles of Care, copies of the monthly report by the provider, training portfolio and details of resident’s activities for a representative week. In addition to this the home completed the Pre-Inspection Questionnaire, which covered areas such as, policies and procedures and personnel. The home also provided prior to the inspection, staff duty rotas and staff Criminal Record Bureau checklist, and the autumn/winter menu. What the service does well: The home is set in a lovely location that allows easy access to Ipswich, but with a rural outlook. The home was decorated for the coming festive season and there was a very homely relaxed atmosphere. Residents were able to sit in a large conservatory used as the lounge, or remain in their room if they chose to. Most of the residents chose to sit in the lounge, with visitors coming and going from the home. The residents all commented on how well they were cared for and how much they liked living at the home. One resident who liked to remain in their room, had regular visits from their family and the family pet. This resident also had an electric keyboard, which they took into the lounge to play for the other residents. Residents asked about activities said that they also liked an opportunity for some quiet time, as well as having the opportunity to take part in activities. The acting manager said that the residents enjoyed the Bell Ringing and the visits by choirs and singers. The home had also taken part in flower arranging and this had involved the local community and had been in the local paper. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 6 The home has made quite a number of changes over the recent months and has plans for improvements. The acting manager and staff are keen for these to take place and feel that this will greatly enhance the quality of life for the residents. The acting manager said these changes would include different use of some rooms, the moving of the laundry and the kitchen. What has improved since the last inspection? 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 DS0000060707.V255916.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 Golden Days DS0000060707.V255916.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): 1, 2 and 3 Service users are having their needs assessed and are provided with a range of information about the home. EVIDENCE: The home had a Requirement at the last inspection around the Statement of Purpose and the need for it to reflect the changes about the new provider. The Statement of Purpose seen during the inspection, from the new organisation, Anchor is now in place. This document clearly gives information to the resident and their families and carers about how to complain. It also gives information about the home individually, with the proposed managers name. The document had not had the alterations of the numbering of the rooms, as this had only just been done. The residents files looked at had the homes new Contract for all the new residents to the home, some of the existing residents Contracts were waiting for the signature of family and carers. Despite these particular Contracts, the home has completed this exercise and the Minimum Standard was met. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 9 The home does make every effort to visit people in their own homes to undertake the initial assessment, as well as when they visit the home. The acting manager said that some prospective residents were in hospital and then the assessment is undertaken there. The initial assessment of two of the residents was looked at and they were found to be appropriate. They each had a photo of the resident at the front of the assessment documentation, the first page covered basic information, with the date of admission. There was also documented equipment that was being used such as spectacles, hearing aids, dentures, fames, wheelchairs and walking sticks. There was also a section on the current medication being taken. The assessment covered the areas of personal details, medical treatment, mental ability, behaviour and emotional developments, other professional contact, family or carer involvement, social interests and hobbies, social worker involvement and ended with a summary sheet. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 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 and 9 Service users have a comprehensive care plan, but these do not reflect their changing needs or their needs when health professionals are involved. Service Users are protected by the homes policies, procedures and practices around medication. EVIDENCE: The home’s care plans are kept in the senior’s room, whilst the resident files are kept in the manager’s office. The residents care plans looked at reflected the admission assessment and was set out in sections covering personal hygiene, dressing, elimination, eating and drinking, communication, mobility, recreation, sexuality and at the end of the care plan was the daily notes. Each of these sections had a number of areas for each section, with a yes/no question. As an example personal hygiene, covered the areas of washing, bathing, hair washing, teeth cleaning and if appropriate shaving. The care plan was quite in-depth, however there was no documentation around any reviews. The daily record reflected the changing needs, but the home does need to make sure that there are monthly reviews and that all areas of care are reviewed. The residents in the home do from time to time; have the Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 11 support of the District Nurses and the home needs to reflect these changing needs in the residents care plan. The home has good policies and procedures on medication, put in place by the new provider Anchor. The administration of medication was observed during the lunchtime. The senior brought the medication trolley into the lounge area adjacent to the dining room. The senior shut the trolley when leaving it to go to residents, to give them their medication. The Medical Administration Records Sheets (MARR), were observed to be completed appropriately. The senior spoken to had acquired a special piece of equipment to cut the tablets in half, the senior said that some of the residents had problems swallowing their tablets and this helped a great deal. The senior spoken to had previously worked in a chemist and had a very good understanding of medication and what was available to support the residents. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 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): 12, 14 and 15 The home provides a range of interesting and stimulating activities for service users. Residents are able to choose how they spend their time and to receive a balanced diet. EVIDENCE: The home has their activities programme on the notice board in the main hall. The home was planning a Christmas party and for residents to go out shopping with staff. The acting manager said that there was groups of singers, the Salvation Army and a choir which always very popular. The acting manager said that they have had hat making and flower arranging that the local community was involved in, which resulted in an article in the local paper. One resident spoken to about activities commented that they also liked some quiet time, without any activities. Another resident visited in their room, said they preferred to spend time in their room and their family member came to see them and their dog came straight up to the room. The manager said that this resident had their own electric keyboard and sometimes played it for residents. The home have reverted one of the downstairs rooms back to another room for the residents and one resident was observed having their lunch in the room. This also gives the availability for residents to have space if they wish to be on their own or to use it when they have visitors. It was also noted that residents used the lounge area fully, sitting in various areas and there was a good deal Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 13 of interaction and laughter. Residents were encouraged to choose where they wanted to be and what they wanted to do. The meals are served from hot trolleys in the small room, with each resident being asked what they wanted for their meals. A menu was seen on notice the boards and all the residents spoken to commented on the good food, one resident said they feed us well. The home’s cook met with the residents and felt since they had changed how they served the meals residents were much happier. The inspector joined the residents during the lunch, the staff made a great deal of effort not to stand over residents while they ate their lunch. This is a difficult balance between the residents being able to eat undisturbed and being able to receive support if they need it. The home needs to review this procedure regularly, to make absolutely sure that this balance in maintained. The residents were offered a choice of Roast Pork or Lasagne, the cook was also happy to do anything else if the residents requested it. The cook said that the residents passed the kitchen door on their way to the lounge and were able to ask for anything they wanted. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 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 People who use this service can expect that any complaint will be taken seriously and investigated and that they will be protected from abuse. EVIDENCE: The home has good policies, procedures and practices in place for complaints and during the inspection various residents and visitors were spoken to. One of the residents had family visiting and when spoken to they were more than happy that any concerns or complaints would be dealt with and listened to. Another resident visited in their room was also sure that any concern they had would be dealt with and that they felt safe living in the home. One resident spoken to said that if they had any concerns they would tell the staff straight away. The residents meeting minutes were looked at during the inspection, the meeting had taken place and there were hand written notes but the acting manager had not had these typed up. It would be of benefit for the residents to have a copy of the minutes of any meeting; these can then be used for future meetings. On the day of the inspection training for adult abuse was taking place in the home. Four of the staff did adult abuse training at the Local Authority training centre at Kerisson and more are doing this in January. The acting manager said that by the end of this training session all the staff would have received training. A member of staff spoken to was clear that any abuse would be picked up and was clear about the procedure for reporting anything of concern. The member of staff also had a clear understanding of the homes ‘no secrets’ Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 15 policy despite this member of staff being one of the last people to receive the training. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 16 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 and 26 People who use this service can expect to live in a clean, well-maintained home, in personalised rooms with specialist equipment available to maximise their independence. EVIDENCE: There are a number of changes and plans being put in place for the home that the acting manager and staff are involved in. The numbering of the residents rooms, which was very complex has been changed and now each room is clearly numbered and it runs in sequence. The home has refurbished their laundry room and this now has new machines, there are plans to move the laundry from the basement. The home is well maintained and the maintenance man was seen to be busy making sure the home is fully functioning. The home currently has an independent occupied flat and at the last inspection there were concerns about access by their visitors. The home has now changed this access and all visitors must enter the home through the main door and sign in and out. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 17 Each of the residents rooms are individually personalised and each room has a key, to allow residents to lock their room if they wish. The home is developing some of its rooms and once they have completed this they will offer residents good quality accommodation. A tour of the home was undertaken and the whole home was found to be clean and free from odours. The home was decorated for the festive season and this gave the home a real homely feel. All the bathrooms and toilets looked at during the tour were found to be clean and had all the appropriate equipment that the residents and staff needed. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 18 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 People who use this service can expect that the number of staff and the training they receive will allow their needs to be met. EVIDENCE: In the past the home has been very reliant on agency staff, to meet the needs of their residents. The staff rota’s and staff files looked at during the inspection now establish that no agency staff have been used for several weeks. The home has undergone recruitment for staff and is in the process of advertising for a deputy manager. The acting manager said that they now have bank staff to call on when the home needs relief and this is the first time that they have had this facility. The acting manager is not part of the care team and is able to supervise and support staff during shifts. The registered manager has now left the home and the acting manager is in the process of an application for registration under the Care Standards Act 2000. Staff files looked at during the inspection all had two references and the Protection of Vulnerable Adults first check and Criminal Records Bureau checks. Each of the files looked at had a number of training certificates, along with identification; employment contracts and interview check lists. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 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, 35 and 38 This home is well managed and there are clear systems in place, but the home are not protecting the residents. EVIDENCE: The homes’ registered manager has left and the home currently has an acting manager that is in the process of registering. The acting manager has very supportive admin and an area manager that supports them. The area manager visits the home twice a month and undertakes a regular monthly review of the home and writes a report and sends a copy to the Commission. The home is in the process of setting up a new banking system for the resident’s money, called the personal money system. There is a database on the home’s computer for all the residents that want the home to support them with their finances. An account is set up on this system and the residents sign an agreement form and there is a cash float kept in the safe. All transactions Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 20 are kept in a written format as well as on the computer database and the resident and/or their families or carers can have a statement at any time. The home do have a fire door wedged open and this is placing the resident at risk, the home does need to make sure that appropriate equipment is in place. In all other areas the home makes sure that its residents are safe and the acting manager has done health and safety training and one of the seniors is awaiting their training. The acting manager will then undertake staff training around all issues with health and safety. The homes records for maintaining water temperatures are very well documented and the acting manager said that the contractor who had been out the day before had also commented on the good recording. The home has make great efforts over recent months to improve the home and the quality of the resident’s lives. There are still some areas that the home need to address, however the staff as a whole were keen to undertake this. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 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 3 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 1 Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 22 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(1) Timescale for action The registered person must 08/03/06 prepare a care plan that reflects the needs of service users who have health needs. The registered person must keep 08/03/06 service users plan reviewed and reflect changing needs. The registered person must take 08/03/06 adequate precautions, including the provision of suitable fire equipment. Requirement 2. 3. OP7 OP38 15(2)(b) 23(4)(a) 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. Refer to Standard OP2 OP12 Good Practice Recommendations The resident’s contracts should be signed and returned to the home as soon as possible. The minutes of the residents meetings should be typed out and each resident receive a copy. Golden Days DS0000060707.V255916.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Suffolk Area Office 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 DS0000060707.V255916.R01.S.doc Version 5.0 Page 24 - 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. 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