Inspection on 27/02/06 for Woodland View Nursing Home

This inspection was carried out on 27th February 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 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 View Nursing Home 02/02/09

Woodland View Nursing Home 16/11/06

Woodland View Nursing Home 06/07/05

Woodland View Nursing Home 16/03/05

Woodland View Nursing Home 07/07/04

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

CARE HOMES FOR OLDER PEOPLE Woodland View Nursing Home Lightwood Lane Off Norton Lane Sheffield South Yorkshire S8 8BG Lead Inspector Mrs Debbie Foster Unannounced Inspection 27th February 2006 7:45 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 DS0000021818.V278704.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. DS0000021818.V278704.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodland View Nursing Home Address Lightwood Lane Off Norton Lane Sheffield South Yorkshire S8 8BG 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) 0114 271 6688/7 0114 253 0714 woodlandview@sct.nhs.uk Northern Counties Housing Association Ltd Deborah Ann Keeling Care Home 60 Category(ies) of Dementia - over 65 years of age (60) registration, with number of places DS0000021818.V278704.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ten places could instead be used for people in the category DE Dementia, who are 55 years of age or over. 6th July 2005 Date of last inspection Brief Description of the Service: Woodland View is a single storey modern spacious home providing care for sixty service users aged sixty-five plus who have dementia. The home can offer 10 places for younger adults in this category from aged 55. The home is divided into four cottages, which have fifteen service users in each. The cottages are domestic in design. Woodland View is situated at Norton, adjacent to Lightwood training centre. The home is close to public transport. There is a large car park. DS0000021818.V278704.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day. The registered manager, 7 staff, and 4 service users spoke with the inspector during this time. Aspects of certain records were checked. Interaction between the staff and the service users was observed. Aspects of the environment were inspected. The inspection started at 7:45 am until 3:15 pm. Feedback on the inspection was given to the registered manager. What the service does well: What has improved since the last inspection? Staff were undertaking NVQ training and they were progressing in attaining their qualification. The home had continued to build on leisure and social activities to undertake with the service users. Some service users were getting out on a weekly basis. A proportion of the previous requirements made in the last inspection report had been progressed. DS0000021818.V278704.R01.S.doc Version 5.1 Page 6 The manager and deputy managers had continued work in assisting and supporting staff to improve the care plans and daily recordings. 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. DS0000021818.V278704.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 DS0000021818.V278704.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): Standards in this section were checked on the last inspection. Standards 3 and 5 met the National Minimum Standards. EVIDENCE: DS0000021818.V278704.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, 9 and 10. In the main the service users health, personal and social care needs were set out in individual plans of care to ensure service users receive the care they need. The administration and storage arrangements for medication were satisfactory to meet the needs of service users. Omissions were found in the recordings of dressing applications to ensure all health needs of some service users were met in full. Service users were treated with respect and their right to privacy was upheld. EVIDENCE: The requirements made at the last inspection were checked for standards 7, 8 and 9. Service users said that the staff attended to their personal care needs and medical assistance provided when needed. Service users said that they were happy with the care they received. Staff were “kind”, “patient”. Staff explained DS0000021818.V278704.R01.S.doc Version 5.1 Page 10 how they met and attended to the personal care needs of service users and how and when health care check up’s and GP. appointments were arranged. The service user plans checked recorded the majority of health care needs and professionals visiting the service users. Dental check ups were recorded as taking place. The detail for pressure sore care in the plan checked had more detail on the treatment required and the progress made than on the last inspection. However, there were still omissions, specific detail on frequency of care and moving to relieve pressure areas was not recorded. The daily notes did not always reflect the service user individual plan in the care given. Risk assessment on falls had been completed and reviewed in the last few months on the two case files checked. Previous requirements made on medication were checked. Medication was stored securely. However the medication administration record sheets checked did not record accurately the administration of dressings. The manager said since the last inspection this issue had been discussed and brought to the attention of the staff on a regular basis. The service users said that the staff were polite and helpful when attending to their personal care and these duties were carried out in private. The staff were able to explain how they would respect the service users privacy. They were seen knocking on bedrooms doors and waiting before entering. DS0000021818.V278704.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, 14 and 15. Service users said they made choices about their daily routines and social activities within the home, which enabled them to make their own lifestyle choices. Service uses were supported and given choice and control in their lives in areas they were able to, promoting their autonomy. The menu at the home offered choices, including healthy options to promote a healthy eating and a balanced diet for the service users. EVIDENCE: Service Users said that they could decide which activities they took part in. Two said they enjoyed listening to music and going out for tea. Another said she joined in occasionally in the board games. Since the last inspection a new mini bus had been purchased. Weekly trips out for Friday tea and Sunday lunch occurred. Some service users went swimming weekly. The staff in each house had liaised with service users and had drawn up a weekly social and activity schedule. There were film afternoons and aromatherapy within these. The variety of social activities for service users had increased since the last DS0000021818.V278704.R01.S.doc Version 5.1 Page 12 inspection. Staff were seen sitting chatting with service users during the inspection. Some service users were observed having a lie in giving choices of daily routine. Service users were given choices of meal options. Their likes and dislikes were recorded within care plans. Food preferences were recorded in the kitchenettes to ensure staff were aware of these. Staff said they asked service users what they would like to wear. Service users bedrooms were individually decorated and were personalised with their own possessions. DS0000021818.V278704.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18. Complaints were acted upon ensuring service users were listened to. However, the recordings systems had omissions. Service users were protected from abuse by the awareness of staff through training and the homes procedures. EVIDENCE: Staff and some service user said they knew how to complain; others did not due to their mental capacity. A complaints procedure was displayed in the home. A service user said that if she had any concerns that she would feel comfortable in talking the manager and felt any issues would be addressed. There had been three formal complaints made since the time of the last inspection. Two were still ongoing. The home did have a recording system for complaints. However, they did not always fully record of the investiagtion process and the outcome of the complaint or if the complainant was satisfied with the outcome. The staff interviewed said they had received adult protection training and the records checked confirmed this. The home had a adult protection policy and procedure and the Department of Health Guidance No Secrets. The home had made two referrals to the adult protection since the last inspection. They had been proactive in reporting incidents and made sure that these were investigated to ensure the safety of service users. DS0000021818.V278704.R01.S.doc Version 5.1 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 the following standard(s): 21, 22 and 24. There were sufficient toilets and bathrooms for the service users. However, some nurse call cords were not accessible to service users near to baths to ensure their safety. Service users have the specialist equipment to meet their needs and promote independence. In the main service users had safe, comfortable bedrooms with their own possessions around them to ensure service users had choice and privacy. Staff were aware of hygiene procedures. The home was clean to ensure a pleasant environment for the service users. EVIDENCE: Previous requirements were checked relating to the environment on this inspection. DS0000021818.V278704.R01.S.doc Version 5.1 Page 15 Bathrooms were in working order. Since the last inspection these areas had been decorated and personalised. This made them more inviting places to use. Service users said they had regular baths. Specialist baths were in place to meet the needs of the service users. Some nurse call cords were not accessible for service users when using the baths. The manager was informed of this. This had been an ongoing issue at the home. Since the last inspection a number of specialist chairs had been repaired and recovered. The staff said there was appropriate aides and specialist equipment to meet the needs of the service users. Service user bedrooms checked were personalised, clean and tidy. In the main the required furniture was provided. A lockable facility is provided on request. The majority of doors do not have a lock for the service users to make a choice to keep their belongings safe or to have privacy. On discussion with the manager she said that this facility would be made available on request and intended to ensure service users and their relatives were aware of this. This information had been included in the statement of purpose. Two bedrooms seen were in need of redecoration. A number of bedrooms had been decorated in the last twelve months and a rolling decoration programme was in place the manager said. DS0000021818.V278704.R01.S.doc Version 5.1 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 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, 28, 29 and 30. The staffing levels were sufficient to meet the full needs of the service users. The home was pursuing NVQ training for staff without the qualification to ensure they would be fully competent in their work and could provide appropriate care to the service users. The recruitment information obtained for permanent staff was sufficient and met the required standard. However, omissions were found on the vetting procedures undertaken for agency and bank staff. Therefore the home did not fully protect the welfare of residents who lived at the home. All staff were not fully trained to do their job to ensure they could meet the needs of service users in all areas. EVIDENCE: The staffing levels met the minimum staffing agreement set with the Commission for Social Care Inspection from the staff on duty on the day of the unannounced inspection and the rotas checked. Staff and some service users said they felt that the staffing levels were sufficient. Staff were seen sat chatting with service users at different times of the day. There was a qualified nurse on duty in each house as well as the support and housekeeping staff. DS0000021818.V278704.R01.S.doc Version 5.1 Page 17 Staff said they did have training opportunities and care workers were undertaking NVQ training. This was confirmed in the records checked. The home had not yet achieved the target set of 50 for its work force to achieve this qualification, however they were well on target to achieve this in the near future. The recruitment information obtained for permanent staff met the required standard. (Including references two references, Criminal Record Bureau CRB and other checks). However, the manager did not obtain such information for staff provided from the Sheffield Trust bank or agency staff. She had been informed that contracts set up stipulated these workers would be vetted as required. This was not sufficient. The manager said she would address this immediately. The staff interviewed said they undertaken the majority of mandatory training (eg health and safety, fire, moving and handling, personal care, adult protection). Since the last inspection some staff had undertaken first aid training. However of the three staff records checked omissions were found in food hygiene, first aid and moving and handling. DS0000021818.V278704.R01.S.doc Version 5.1 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 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): 33, 35, 36 and 38. Effective quality assurance systems were not fully in place to pick up on all omissions and mistakes. Although a number of areas were audited to ensure the home is running in the best interest of the service users. The home had systems in place to safeguard the financial interests of the service users they were supported by recording transactions and holding receipts. Staff were not being formally supervised at the frequency specified in the Regulations and Standards to ensure individual staff development and the monitoring of care practices. In the main the health, safety and welfare of service users and staff were promoted and protection was in place. Some mandatory training for staff had not been provided in full to ensure service users safety at all times. DS0000021818.V278704.R01.S.doc Version 5.1 Page 19 EVIDENCE: The requirements made only on the last inspection were checked for standards 33, 36 and 38. Effective quality assurance systems were not fully in place to pick up on all omissions and mistakes. The manager had been developing this area further since the last inspection. A number of areas were audited to ensure the home is running in the best interest of the service users. The manager said that the home handled a number service users personal allowances. Two records were checked, there were income and expenditure recorded and receipts were kept. The accounts were overseen by an external source. One service user said she could access her money when she wanted it and could spend it on what they liked. Other service users were supported to handle their money. Staff undertook shopping for them. The home liaised with relatives on the spending of service users money were appropriate. The frequency of formal staff supervision had improved since the last inspection. However, not all staff were not being formally supervised at the frequency specified in the Regulations and Standards to ensure individual staff development and the monitoring of care practices. Aspects of Safe Working Practices were checked on this inspection. Staff interviewed said they had received fire instruction training in the last six months. Service users risk assessments had been reviewed. Omissions were found in the training of staff already commented on in other areas of the report. DS0000021818.V278704.R01.S.doc Version 5.1 Page 20 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 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 X X 2 3 X 3 X x STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 2 DS0000021818.V278704.R01.S.doc Version 5.1 Page 21 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 Standard OP8 OP7 Regulation 15 Requirement Detailed action, which needs to be taken by staff to meet the needs of service users, must be recorded in the service users care plan. Daily recordings must record and reflect the care given in line with the service users care plan. The service users medication record must accurately record administration of dressings. This requirement had been outstanding since March 2005. The details of investigations and the outcome of complaints must be recorded. Along with the details of whether the complainant is satisfied with the outcome of the complaint. Nurse call cords must be accessible to service users when using the bathing facilities. This requirement had been outstanding since March 2005. All bedrooms must be decorated to a satisfactory standard. Timescale for action 28/05/06 2 OP9 12 & 13 28/04/06 3 OP16 22 28/04/06 4 OP21 23 28/04/06 5 OP24 23 28/07/06 DS0000021818.V278704.R01.S.doc Version 5.1 Page 22 6 OP29 19 7 OP38 OP30 OP38 OP30 18 8 18 9 OP33 24 10 OP36 18 Recruitment checks must be carried out on all staff (bank and agency staff) working at the home in line with Regulation 19 and Schedule 2. The manager was informed to take immediate action. Staff must receive all mandatory training; including Food hygiene Health and safety The home must ensure that staff receive first aid training appropriate to their role and duties and in line with legal requirements. A rolling programme must be put in situ. This requirement had been outstanding since March 2005. The quality assurance system must be developed further to ensure the best interests of the service users, and that aims and objectives are met. Information from questionnaires seeking the opinions of service users and/or their relatives/ representatives must be collated and made available to them. This requirement had been outstanding since July 2005. All staff must receive formal supervision at the stipulated frequency of six times a year. This requirement had been outstanding since 2004. 05/03/06 28/05/06 28/04/06 28/06/06 28/04/06 DS0000021818.V278704.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations The home must have a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent). DS0000021818.V278704.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000021818.V278704.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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