Inspection on 06/07/05 for Woodland View Nursing Home

This inspection was carried out on 6th July 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 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 27/02/06

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 Lightwood Lane Off Norton Lane Sheffield S8 8BG Lead Inspector Debbie Foster Unannounced 06 July 2005 09:40 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. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodland View Nursing Home Address Lightwood Lane Off Norton Lane Sheffield South Yorkshire S8 8BG 0114 271 6688 0114 253 0714 Not Available Northern Counties Housing Association 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) Deborah Ann Keeling N Care home with nursing 60 Category(ies) of DE(E) Dementia - Over 65 (60) registration, with number of places Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 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. Date of last inspection 16 March 2005 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. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 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, 12 staff, two relatives 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 9:40a.m. until 17:40pm. Feedback on the inspection was given to the registered manager. What the service does well: What has improved since the last inspection? A number of staff had been enrolled on NVQ training. Conservatories had been built onto each of the four bungalows to further enhance the communal space for the service users. A new mini bus had been purchased to assist in regular trips out for the service users. The home had continued to build on leisure and social activities to undertake with the service users. The majority of the previous requirements made in the last inspection report had been progressed. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI 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 Woodland View J55-J06 S21818 Woodland View V236340 060705 UI 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) 3 & 5 No service user moves into the home without having his or her needs assessed to be assured that these will be met. Prospective service users and their relatives have the opportunity to visit and assess the quality, facilities and the suitability of the home to assist them in making a decision about whether they wish to live at the home or not. EVIDENCE: The manager said that all service users are needs assessed prior to admission to ensure that their needs can be met once moving into the home, the records checked confirmed this. The assessments checked covered the areas set out in standard 3.3. Relatives informed the inspector that they had visited the home to check out the facilities on offer prior to service users making decisions to come and live there. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 & 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: Aspects of the service user plan were checked in relation to requirements made on the last inspection. The care plans had been reviewed on a monthly basis. The service user plans included cultural and religious needs and the action taken by staff to meet the needs identified. The manager said the risk assessments on falls in the main had been completed and updated although there was still some work to be undertaken in this area. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 Page 10 Service users and a relative said that the staff attended to their personal care needs and medical assistance provided when needed. Service users said that they were happy in the home and said, “I like the staff and get on with them ” and ”I’m happy here”. A relative said they were “very satisfied” with the care delivered by staff. The service user plans checked recorded the majority of health care needs and professionals visiting the service users. However, omissions were found. Dental check ups were not recorded as taking place. The detail for pressure sore care in the plan checked was not detailed enough in the treatment required and the progress made. The daily recordings did not always detail all the care given to reflect the service user individual plan. Previous requirements made on medication were checked. Medication was stored securely. Medication Administration Record sheets checked indicated that no medication was out of stock. The manager said that risk assessments for service users handling their own medication would be undertaken when such circumstances occurred. However the Medication Administration record sheet 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. 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. 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. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 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 standard(s) 12, 13, & 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. Further development in the scope of activities available in the home for service users would be beneficial to enhance the service users quality of life further. Service users maintained contact with family and friends to enable them to continue community links. 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. One said she enjoyed the social events and having her nails manicured and hair set weekly. Another said she joined in occasionally in the board games. Two relatives and some staff said they thought there was room for improvement in the activities undertaken with service users. A new minibus was due to be delivered to help with outings. Some service users went swimming weekly. Relatives said they visited the home often and were made welcome. Service users were seen to be given choices of meal options. Some service users were observed having a lie in giving choices of daily routine. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 Page 12 The home has a relative support group which meets at regular intervals. One relative raised concerns about how it was organised. Relatives and service users said visiting times were flexible. They were made welcome and always offered a drink. Service users said the quality of food served was good and that “there was always a choice”. Menus offered a choice of food at each mealtime. Service users said that they enjoyed their lunch. Drinks were taken around the home in between meals. The meal times were unhurried and a relaxed atmosphere was noted. Some service users were seen being assisted to feed appropriately by staff. Some staff said that the options would benefit from being extending further at lunchtime such as offering a cold option. A relative said she thought there should be more salad and fresh fruit on the menu. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI 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) None on this inspection. The key standards will be checked on the next inspection. EVIDENCE: Woodland View J55-J06 S21818 Woodland View V236340 060705 UI 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) 19,21, 22, 24 and 26. Service users live in a well-maintained environment to ensure their safety and comfort. 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 there safety. Service users have the specialist equipment to meet their needs and promote independence. However some equipment was not being promptly repaired. In the main service users had safe, comfortable bedrooms with their own possessions around them. However, not all specified furniture was in place in all rooms and locks were not in place on all bedroom doors to ensure service users had choices about privacy and security. Staff were aware of hygiene procedures. The home was clean to ensure a pleasant environment for the service users. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 Page 15 EVIDENCE: Previous requirements were checked relating to the environment on this inspection. The manager and staff said the home had a routine maintenance and redecoration programme. En suite areas in one house had recently been decorated, during the inspection two bedrooms were being decorated and a bathroom was to be decorated within the week. The grounds were tidy and attractive. The manager said that uneven paths used by the service users had been repaired. Bathrooms were in working order. These areas were in the process of being decorated, some were finished and personalised some were still to be completed. 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 and took immediate action to remedy the situation. Some specialist chairs in one house were in need of repair. Staff said these had been reported although one such repair had been outstanding for some time. Other specialist chairs had been identified as in need of repair and quotes obtained to have them 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. Some rooms did not have chairs or bedside tables. Bedside lights were not always accessible to all service users once in bed. On the day of the inspection the home was fresh smelling, clean and tidy. Carpets in corridor areas were clean and no stains were visible. The housekeeping staff said that there was a carpet-shampooing programme which meant that all communal areas were cleaned every week. Staff explained the procedures they followed to ensure hygienic practices and the control of infection. The home had a policy and procedure to follow on the control of infection and for the handling of clinical waste. Service users and the staff said that clothing and linen came back from the laundry clean and in good condition. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI 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, 28 & 29. 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 staff was sufficient and met the required standard to adequately protect the welfare of residents who lived at the home. Two positions within the management team were temporary and this had been the case for some considerable time. The manager was optimistic that this situation would be resolved in the coming months. 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 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 staff. Staff said they did have training opportunities and care workers were undertaking NVQ training. This was confirmed in the records checked. Staff said they had received an induction and additional training had been given on Abuse of Older People and the Care of People with Dementia. The home had not yet achieved the target set of 50 for its work force to achieve this Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 Page 17 qualification. Since the last inspection the home had registered a further six staff to undertake NVQ 3 training and further five were to commence the qualification in October 2005. The recruitment information obtained for staff met the required standard. The staff files checked contained references two references including one from the staff members last employer and or a managers assessment. The manager said all staff had Criminal Record Bureau (CRB) checks this corresponded with the files checked. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI 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) 33, 36 & 38 Effective quality assurance systems were not fully in place to pick up on omissions and mistakes. Although a number of areas were audited to ensure the home is running in the best interest of the service users. 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. First aid training had not been provided to a sufficient number of staff to ensure service users safety in this area at all times. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 Page 19 EVIDENCE: The manager said that quality assurance systems were being developed further to monitor the service and care provided in the home. However, omissions were found in case files and medication systems. The home had not yet collated service user and relative feedback on the service. Staff said that supervision was taking place to ensure the standard of care practices were being monitored. However this was still to be implemented and provided at the required frequency stipulated in the standards. The staff said that their supervisors were approachable and any issue was discussed and action taken where required. Aspects of Safe Working Practices were checked on this inspection. The home had actioned the requirements made on fire safety made on the last inspection. Two fire drills had been undertaken. Staff interviewed said they had received fire instruction training in the last six months and the records checked confirmed this. A fire door had been replaced. Equipment had been serviced in the last twelve months. The manager said that risk assessments were being updated on a regular basis. The manager said there were six staff trained in first aid within the work force. This did mean that there might be some shifts when a first aid trained person may not be working which could have safety implications for the service users. The manager said the training plan for this year was going to include some first aid training for staff. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 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 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 2 2 x 2 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 2 x x 2 x 2 Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 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 OP7 Regulation 15 Requirement Comprehensive risk assessments on falls must be undertaken for all service users. These must contain measures taken to prevent falls and action to be taken by staff. This requirement has been outstanding since March 2005. All health care check ups must take place and be recorded. The service user plan must record specific detail in pressure sore care, action taken and the outcome. The service users medication record must accurately record administration of dressings. Activities must be developed further to ensure service users lifestlye, social and leisure and preferences are satisfied The damaged decoration in bathrooms must be rectified. Bathrooms must be personalised. This requirement has been outstanding since 2003. Nurse call cords must be accessible to service users when using the bathing facilities. Damaged specialised chairs for Timescale for action 28.8.05 2. OP7 & OP8 12 & 13 28.08.05 3. 4. OP9 OP12 12 & 13 12 07.07.05 28.09.05 5. OP21 23 28.07.05 07.07.05 28.08.05 Page 22 6. OP22 12 & 23 Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 7. OP24 23 8. OP1 & OP24 4 & 23 9. OP33 24 10. OP36 18 11. OP38 18 service users must be repaired or replaced. This requirement has been outstanding since March 2005. All bedrooms must have the specified bedroom furniture set out in standard 24. If there are identified reasons for these not to be provided then this must be recorded in the care plan.Light cord switches must be accessible to service users when in bed. The service user guide and statement of purpose must include information for service users and relatives that lockable facilities and door locks will be provided up on request. 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. All staff must receive formal supervision at the stipulated frequency of six times a year. This requirement has been outstanding since 2004. 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. . 28.09.05 28.09.05 29.10.05 28.08.05 28.10.05 28.08.05 Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 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. 2. 3. 4. Refer to Standard OP13 OP15 OP28 OP29 Good Practice Recommendations A review of the relative support group should occur to attain if the persons involved are happy with how it operates. When reviewing the menu the comments from service users, staff and relatives should be taken into account and included in the menu to enhance it further. The home must have a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent). There should be a permanent and complete management team to ensure the continued quality of care in the home for service users. Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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 Woodland View J55-J06 S21818 Woodland View V236340 060705 UI Stage 4.doc Version 1.40 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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