Inspection on 10/02/06 for Woodland Villa

This inspection was carried out on 10th 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 Villa 16/04/08

Woodland Villa 06/11/07

Woodland Villa 13/02/07

Woodland Villa 24/05/06

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Woodland Villa 93 Alma Road Plymouth Devon PL3 4HE Lead Inspector Doug Endean Unannounced Inspection 10th February 2006 09:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodland Villa Address 93 Alma Road Plymouth Devon PL3 4HE 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) 01752 669625 Denmax Ltd Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability over 65 years of age of places (34) Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/05/05 Brief Description of the Service: Woodland Villa is a “care home with nursing” that is registered to provide personal care for up to 19 clients, and nursing care for up to 34 clients. It can therefore admit up to 53 clients over the age of 65 years old and of either gender. It has been developed over several years from a terrace of houses that have been joined together internally, and adapted to meet the demands placed upon it by the clients, many being disabled through illness. Ramping and passenger lifts have been provided to enable clients to access to all parts of the home. The home is on the outskirts of Plymouth city and is on the bus route to the city centre. There is access also to some local amenities. The home has recently passed into new ownership and the company Director was at the home during this inspection and provided the inspector with evidence of the work that he has already had done and also produced a plan of work to be completed over the next twelve months. The home still has a residential unit at one end and the nursing home takes up approximately two thirds of the property. The units share the same main kitchen and laundry. There is good shared communal space at each end of the building that is well proportioned, attracively decorated and offers several separate areas for the clients to sit in with other cleints or their visitors. There is a small outdoor area that has some seating for the clients to use in times of good weather. There is also a reasonable sized car park for people using the home. The nursing unit is managed by registered nurses 24 hours a day who are supported by social care staff. Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report should be read along side of the previous report in order to establish the homes performance against the National Minimum Standards during this inspection year. This unannounced inspection took place on Friday 10th February 2006 commencing at 09.50 hours and lasted approximately 3 hours. The Registered Individual was present during the inspection and provided the inspector with evidence of the work carried out at the home since the last inspection and how care practices have improved. The inspector saw two samples of staff files, two samples of clients files, and spoke to 2 staff members, 5 clients and two relatives during a tour of the home. The inspectors over all impression are that the home is improving rapidly in many ways. The staff are implementing improved record keeping systems that have had an effect on the actual care they deliver by identifying shortfalls that may have occurred in the past. The clients that were spoken to expressed their satisfaction with the care they receive and the attention that the new owner is paying to them and the home. The physical changes to the building that have already taken place, and that are planned, show both a knowledge of priorities to make a home safe to a high standard, and a desire to provide the best service possible. The inspector will be interested to watch the metamorphosis of the home over the next year. What the service does well: What has improved since the last inspection? The response to the regulations made at the last inspection has been very positive with a new care planning system and evidence about how the care is then delivered. Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 6 The safety of the environment has improved with the new fire alarm system and the completion of the full electrical rewiring of the home amount some of the changes that have been made. The clients were very animated and willing to voice their opinion about the positive changes that have taken place. 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 Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodland Villa DS0000064463.V269693.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): 1 There is a satisfactory amount of information provided to clients so that they can make an informed decision about whether the home will suit them before making admission arrangements. EVIDENCE: The home has a Statement of Purpose that is satisfactory. A copy of this was shown to the inspector who was also told that this will be fully reviewed as the new owner progresses with the work that has been commenced to bring the home up to his specifications. The Statement of Purpose is given to each client along with the contract of residency. Woodland Villa DS0000064463.V269693.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&9 The newly introduced record keeping and care planning process is very good and will be more than satisfactory when implemented across the whole of the home. EVIDENCE: The care planning process was found to be less than robust during a complaint investigation. The new Nurse Manager of the home took up post when the home changed hands and has begun to address this situation. The inspector saw examples of the new methods that are used to record information including nutritional assessments, manual handling assessments and other health related assessments. This information is produced and a well written care plan for each separate issue was seen that provided clear guidance on how care is to be delivered and who will deliver it. An additional record sheet, which reads like a calendar, indicates by signature who has dealt with each of the tasks of daily living for each individual client. The names and sample signatures of staff are also in the files providing clear and swift evidence of the person who is stated to have carried out a task. The new methods of record keeping/care plans are a big improvement on what the home has used in the passed. It is being adopted at a realistic pace across Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 10 the home and will prove to be more than satisfactory when this has been achieved. The Nurse in charge during the inspection said that all the staff have had the new system of recordings explained to them and have adopted an enthusiastic approach to using them. One care staff member that was spoken to agreed with this statement. There was still no evidence that the drug fridge temperatures are being taken although there is a fridge thermometer in the fridge. Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The home has achieved the balance between choice, care and independence that is expected of them by the clients who live there. EVIDENCE: The inspector reported fully on this section during the previous inspection and this should be read along side the following comments. During this inspection the inspector spoke to five clients who wished to express their satisfaction with the improvements in the way the home has been managed to their benefit since the change of ownership. They paid many compliments about the Registered Individual, Mr Patel, and the staff stating their whole hearted satisfaction with the food, the environment, the entertainment, the care and the attention they receive. Those who are able do enjoy as much independence as they are capable of such as going for walks, doing some shopping locally or enjoying the company of their pet who also lives at the home. The inspector spoke to two relatives who were also visiting the home and they supported the views given to him about the improvements that have taken place since the change of ownership in the overall way the home is functioning for the clients benefit. The activities include a monthly religious service and communion at the home, music and movement twice a week, and entertainment. The events occur in Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 12 both the residential end of the home and are repeated in the nursing home lounge. Following a complaint the home has improved their nutritional assessment, recording weights, foods served and eaten by the clients and how their fluid intake is being met. Woodland Villa DS0000064463.V269693.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 & 18 The complaints procedure is robust and does approach complaints from a reactive position rather than a defensive one. The record of complaints is well structured showing the path taken from beginning to end. The standard of Adult protection training is good as it is with a recognised trainer and should continue until all staff has attended. EVIDENCE: The core standards were reported upon during the last inspection however the inspector wishes to add that during this inspection the Registered Individual showed how the home addressed a written complaint from a relative. The complaint was read and recorded. The home investigated the issues raised, made their own investigation and written report then met with the complainant to agree on the future care plan. The process that was adopted was positive and has resulted in changes that will benefit the client. There are ongoing reviews occurring to establish the result of the changes and also how the home can engage the relatives further in meeting future needs. A further outcome of the complaint is that the home now has an improved nutrition assessment and recording system that was looked at during the inspection. It clearly identifies the nutritional needs of each client, what is provided at each meal and what is eaten. There are also good records of fluid intake and output where this has become an issue. The inspector saw evidence that the staff have, and continue to attend Adult Protection training that is being provided by Plymouth City Council. Woodland Villa DS0000064463.V269693.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): 19, 20, 21, 22, 23, 25 & 26 The activity that has taken place in respect of improving the environment has been provide a safer and more comfortable place for both the clients to live in and the staff to work in, and is continuing. EVIDENCE: The home is in transition with the new owner/ Registered Individual spending a good proportion of his time overseeing the many environmental changes that have taken place and are in the plan to occur over the next year. The inspector was shown the plan and saw the work that has already taken place during the tour of the home. The house has been totally rewired and this work was completed on the 9th February 2006. Only redecoration is needed to bring the work to an end. This will occur when other work has been finished. There are now new thermostatically controlled mixer valves to every wash hand basin and bath in the home. A new fire alarm system has been fitted, and a new nursing call system has been installed that requires the staff to wear a pendant during duty to cancel the call in the clients room who has raised the alarm. In addition to this the telephone system has been upgraded and staff can carry a phone unit Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 15 to allow them to be contacted anywhere in the home and also to respond to outside calls without needing to be in the office. For clients who do not have a telephone of their own they could use this system to receive calls although there is a public phone system available in the residential lounge area. New radiator guards have been fitted to all the radiators in the home. Bedrooms are also being refurbished on a priority and vacancy basis. Doors are being fitted with self closures that are linked into the new fire alarm system so that clients can exercise their choice in having their room doors open if they wish without this compromising their safety. The window above ground floor have been fitted with restrictors where their design has required them to be fitted. The improvements plans include the installation of appropriate disinfecting sluices in the nursing unit and there was evidence that these have been ordered. When all the work is completed as planned the home will be fully up to date in providing a very good standard of safety and comfort for the clients and staff. There is ample communal space provided at the home that is shared by residents and patients. Large lounges that are thoughtfully designed and furnished provide intimate areas for clients to sit are at each end of the ground floor. There is also dining room space provided in addition to the lounges. Activities can take place and still allow clients, who do not wish to take part, to sit in one of the other lounge areas relatively undisturbed. The conservatory provides excellent visual stimulation from the front garden and the busy main road without any excesses of noise. The home is adequately lit either naturally or artificially such as in the internal corridors. The home has experienced many appropriate adaptations to benefit the clients who may have a disability such as ramping and passenger lifts, disabled bathing and toilet facilities, handrails where they are beneficial, and the new nurse call system. Some bedrooms have the benefit of en-suite facilities that may be a toilet and wash hand basin or a well planned domestic style bathroom. There is a satisfactory provision of toilets available to clients when they are using the communal spaces. The home has its own separate laundry that has a washing machine that has a sluicing cycle within its programming. There is also a commercial dryer in the laundry and each client has there own named laundry basket to assist in the delivery of cloths back to the right person. Woodland Villa DS0000064463.V269693.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): 28 & 29 The recruitment procedure is not sufficiently robust as staff files do not hold the level of information that is required by legislation. Staff training is satisfactory although the standard of 50 of care staff having a National Vocational Qualification at level 2 or above has not been achieved at this point in time. EVIDENCE: A sample of staff files were seen and found not to be complete. The Administrator told the inspector that some staff have not provided him with the information that he has requested to complete the files to that required by the Care Homes Regulations 2002, Schedule 2. The importance of this information was discussed. All staff have a current Criminal Records Bureau check and this would entail the checking of various forms of identification, some files however have photographs and other means of identification whilst some do not. The inspector observed that the staff levels during this unannounced inspection appeared to be satisfactory. A copy of the staff rosters for the month of February was taken and this does show that adequate numbers of staff are employed each shift to provided care and ancillary services throughout the building. The clients that spoke to the inspector felt that staffing levels were satisfactory and that they did not wait for any unacceptable periods to have their needs attended to. There have been changes to the management structure at the home that did have a manager for the nursing unit and one for the residential unit. There is now to be a one manager for all the care throughout the building. Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 17 The staff receive adequate training that includes training to National Vocational Qualification level. There are two National Vocational Qualification assessors on the care staff team, one being a care staff member and one being a registered nurse. Approximately 33 of staff have a National Vocational Qualification at level 2 or above at the present time. Woodland Villa DS0000064463.V269693.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): 31, 35 & 38 The home care of the clients and management of the home is good and improving despite the position of Registered Manager being effective vacant at present. The upgrading, maintenance and training have provided a safe environment for the clients to live in. EVIDENCE: The home had a new manager who began work during the late summer of 2005. She did make application to the Commission for Social Care Inspection for the role of Registered Manager. She also made several changes to systems at the home such as the planning and delivery of care including better ongoing assessments. Unfortunately she has withdrawn her application days prior to this unannounced inspection due to ill health. The home continues to function well under the control of the Registered Individual and the care staff led by registered nurses. A person has been recruited, from the existing staff, to the post of manager and she will make application for the position of Registered Manager when she is fully in post at the home. Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 19 The home is not financially responsible for the financial affairs of any of the clients. They do have robust procedures for handling any monies held for clients and have secure facilities for its storage. The upgrading of the systems reported upon in standards 19 to 26 along with general maintenance on such things as hoists and hot water boilers have provided a safe environment for the clients and the staff and do show a commitment by the new Registered Individual to achieve a high standard for the home. In addition the training that staff are subjected to and the positive comments from the clients are more positive indicators that this standard is met. Woodland Villa DS0000064463.V269693.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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 X 3 3 STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 3 Woodland Villa DS0000064463.V269693.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 OP29 Regulation 19(1)(5) Schedule 2 Timescale for action The Registered Person shall not 31/03/06 employ a person to work at the home unless he has obtained in respect of that person the information and documents specified in Paragraphs 1 to 7 of Schedule 2. The staff files seen did not hold this level of information. Requirement 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 OP7 Good Practice Recommendations The home should carry on the introduction of there new record keepings and care planning arrangements until they are adopted across the whole home as they are an example one example of recording the delivery of care in a clear and informative way without being difficult or time consuming. There should be a record of the drugs fridge temperatures made on at least a weekly basis and the record made available for inspection. DS0000064463.V269693.R01.S.doc Version 5.1 Page 22 2 OP9 Woodland Villa 3 4 OP18 OP31 The staff should continue with Adult Protection training until all the care/nursing staff have attended. Keep the Commission for Social Care Inspection informed of the commencement date of the newly recruited manager when this is known. Woodland Villa DS0000064463.V269693.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Villa DS0000064463.V269693.R01.S.doc Version 5.1 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. 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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