Inspection on 10/08/05 for Woodlands

This inspection was carried out on 10th August 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

Woodlands 25/08/06

Woodlands 07/02/06

Woodlands 30/03/05

Woodlands 27/10/04

Woodlands 04/03/04

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

CARE HOMES FOR OLDER PEOPLE Woodlands Woolley Moor House Low Moor Lane Woolley WF4 2LW Lead Inspector Pat Pedley Unannounced 10 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodlands Address Woolley Moor House Low Moor Lane Woolley WF4 2LW 01924 830234 01924 830019 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) John & Anne Kelly Mrs Sandra Goodall Care Home 27 Category(ies) of Older People - over 65 years - 27 registration, with number Physical Disability - over 65 years - 27 of places Mental Disorder - over 65 years - 27 Dementia - over 65 years - 27 Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 30 March 2005 Brief Description of the Service: Woodlands is a care home registered for the care for 27 older people some who may have Dementia, Mental Illness, Mental Disorder and Physical Disability. The building is set in the beautiful countryside near the village of Woolley on the outskirts of Wakefield. The views from the home are spectacular. It is a two-storey building, which is accessible by ramp. The service users have access to all parts of the home by ramp or shaft lift. There is a summer house where residents can sit and enjoy the view. All rooms are single occupancy and have en suite facilities. The service users health needs are provided by the local Health Centre and local Hospitals. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home taking place over a 5-hour period. A good number of residents and their visitors spoke with the inspector and time was spent talking with the manager, staff, examining records and looking around the home. What the service does well: What has improved since the last inspection? What they could do better: Care plans are in need of further development so that all needs are clearly identified and staff understand how they can meet those needs. Recommendations have been made for the home to deal with repairs and maintenance including checking the fire retardancy of upholstered chairs, attending to the flat roof and subsequent water damage and some minor redecoration of the home. Water temperature checks must be carried out regularly. The homes maintenance records should be up to date with copies of current certificates being held in the home for inspection purposes. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 6 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. Woodlands J51J01_s6241_woodlands_v243818_100805.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 Woodlands J51J01_s6241_woodlands_v243818_100805.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) 5 & 6 Satisfactory arrangements are in place for introducing new and prospective residents into the home. EVIDENCE: One resident and two visitors told the inspector how they had come to choose the home. They said that they had been able to look around and meet other residents and staff and had chosen the home because of its welcoming atmosphere. They said that they had never regretted the decision. The home does not provide intermediate care. Woodlands J51J01_s6241_woodlands_v243818_100805.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 There is a need to fully develop care planning systems so that needs are fully identified and that staff can be made fully aware of the action to be taken to meet those identified needs. Residents are happy and satisfied that staff treat them with kindness and respect. EVIDENCE: A number of care plans were examined. There was good evidence that healthcare needs are being met in the record of healthcare professional visits. Discussion took place about care plans as it was unclear from those seen what the residents needs were and what needed to be done by staff to meet identified needs. Advice was given as to how care planning could be improved. The manager said that she welcomed such advice and would make changes to develop effective care plans. Residents said that staff are very good and treat them with respect. The inspector also formed this view whilst observing staff carry out their duties. Medication records were found to be satisfactory on the day of inspection. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 10 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 Satisfactory arrangements are in place to ensure that residents maintain an active lifestyle and are provided with a choice of nutritious meals. EVIDENCE: Residents said that they had enjoyed their Summer Fayre and particularly the band, which had come to play there. On the day of inspection, residents were seen enjoying a quiz with staff. Several residents spoke with the inspector, it was pleasing to see how many friendships had formed in cosy corners and residents were chatty and responsive to discussion. Many positive comments were heard about the home, staff, food and activities. Several visitors were present throughout the visit. They said that they were always made to feel welcome and enjoyed coming to visit their relative and that the care given was excellent. Residents said that they had plenty of choice of food. A full traditional breakfast is offered everyday. The manager had helped cook the lunchtime meal. This was sampled and found to be very satisfying. Residents said they enjoyed their meals. A good and varied choice of sandwiches was available for tea. It was pleasing to see that choices were different from the norm and that they had been freshly made. The manager said that the cook is undertaking Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 11 the Intermediate Food Hygiene Certificate and she herself has completed this training. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Satisfactory arrangements are made for dealing with complaints. It would be of benefit for staff to receive further training so that they fully understand what to do should there be an allegation of abuse. EVIDENCE: The manager said that the home has received no complaints since the last inspection. She said that she has an open door policy and residents said that they can go to her anytime and any concerns will get sorted out straight away. The complaints procedure that was on display showed that it needed to be amended as the telephone number of the Commission was incorrect. The details of the Parliamentary Ombudsman need to be added as to detail of the timescales for dealing with a complaint. The manager took the procedure from the wall straight away and made the necessary amendments. Two staff were interviewed and were asked how they would deal with an allegation of abuse. Their response showed that they might benefit from further refresher training on local reporting procedures. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24 & 25. The home provides a homely, clean and cosy environment for service users in keeping with the location and style of the home. This could be further enhanced by attending to some maintenance issues such as carrying out regular hot water temperature checks, checking fire retardancy of furniture and checking the flat roof. EVIDENCE: The homes manager showed the inspector around the home, which was found to be clean, cosy and homely. Some communal areas would benefit from being “freshened up “ soon and the manager said that the providers were supportive of changes being made. The homes exterior was found to be well presented and the gardens are kept in excellent condition. There was patio furniture and a nice wooden summerhouse looking over extensive views. Residents said that they like sitting outside in the nice weather and one took her visitor outside to the summerhouse during her visit. Each dining table was nicely laid out with tablecloths, linen napkins, condiments and flowers. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 14 Residents said that they are able to smoke in the conservatory. The home has a pet cat. The manager said that some of the homes ceilings have been lowered and ceiling tiles fitted. Water damage was seen in some areas where the rainwater from very recent bad weather had entered from the flat roof. In one corridor area the ceiling tiles were so damaged to be exposing the ceiling void above. The manager said that this was going to be attended to be the handyman. The carpet on the top corridor was found to be “ruffled” and the manager said she would have this attended to. The inspector looked in a number of bedrooms. These were pleasantly furnished and residents were seen to be encouraged to bring their own possessions to the home. Some chairs in bedrooms were seen to be of an older style and fire retardancy notices were not seen on some items of furniture. This was discussed with the manager and it was suggested that a review of upholstered chairs should be carried out since she said that some chairs belonged to residents. Bathrooms were examined and one was found to be in need of re-decoration and the shower room upstairs was difficult to enter as it was wedged shut. The handyman said that he would see to the door straight away to ensure no one got locked in. The last record of water temperature checks seen was dated 24/03/05. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 15 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 & 30 Staffing levels are maintained at a satisfactory level and arrangements for staff recruitment must be reviewed to ensure safe practice. EVIDENCE: It was found that there were good staffing levels on the day of inspection. The inspector joined the staff handover after lunch. It was good to hear and see evidence of good communication about service users including identifying both needs met and needs to be attended to later in the day. There was evidence that several handovers are carried out throughout the day. From looking at a sample of staff files it was seen that health questionnaires were needed as some were found to be missing. One staff file needed a number of records required by Regulation including a full employment history, details of referees and proof of identity. From discussion with the manager and examining records staff training is provided where appropriate. The Community nurse has provided a 4-week course to staff on Dealing with Aggression recently. The manager said that over 50 of the staff team have now completed NVQ Level 2 and 3 more staff have recently enrolled for the training. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35 & 38 The home is well managed and residents and staff respect one another. This is achieved through the use of effective communication practices. Copies of the homes maintenance certificates must be held in the home so that the Commission can be assured of regular safety checks being carried out. EVIDENCE: The manager said that she has nearly completed the Registered Managers Award. Staff said that the manager was “lovely” and they felt well supported. This view was confirmed by residents who were full of praise for the staff team in general. At the time of the visit the manager was busy helping get dinner ready as the cook was on holiday, she had helped with the cleaning the day before. She said that she helps staff with the daily routines as much as she can given her Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 17 other responsibilities as all employed there are part of a team working to ensure the home runs for the benefit of residents. From discussion with staff, residents and observations made on the day residents are very much the focus of the home and there was a lively atmosphere throughout the day. The manager said that she does not handle resident’s monies. Any extra services are dealt with through invoices to residents from the service provider e.g.: hairdresser. Fire testing records were examined and found to be satisfactory. Fire drill and training records were up to date. A fire risk assessment was seen to be in place. Copies of the homes maintenance certificates were requested and it was found that the last copy of the annual fire alarm, emergency lighting and extinguisher certificate was dated June 2004. The home is fed by gas from tanks. The last recorded annual safety certificate seen was dated 1997. The manager said that annual checks used to be carried out and will check what the maintenance schedule is currently. There was some uncertainty about whether a water chlorination certificate was held although the manager said that an outside company checked the water regularly. The current insurance certificate was not seen. The manager said that the registered providers might have the relevant copies of the necessary certificates as they live in a separate house within the homes grounds. It was discussed with the manager that Regulation 26 reports had not been sent to the Commission for some months as required at the last inspection. She said she would remind the Registered Provider to send them on as the report had been carried out. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 18 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 x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 1 x 3 2 3 x STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x 3 1 x 1 Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 19 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP21 Regulation 13(4) Requirement Water temperatures must be checked monthly and the outcome to such checks recorded. Staff records must include all details required by Regulation including a full employment history, health questionnaire, details of referees and proof of identity. Copies of the current maintenance certificates must be forwarded to the Commission. Where the registered person is an organisation or partnership, the care home shall be visited by the responsible individual or one of the partners in accordance with this regulation and send monthly reports to the Commission. Timescale for action Immediate and ongoing Immediate and ongoing 2. OP29 !9, Schedule 2 3. 4. OP38 OP36 23(2)c) (4)(c ) 26(2) 31 October 2005 30 September and ongoing RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 20 1. 2. 3. 4. 5. 6. OP7 OP18 OP19 OP24 & OP38 OP21 OP19 Care plans need developing further to clearly identify individual needs as well as the action to be taken by staff to meet them. Staff may benefit from refresher training on the Mistreatment of Vulnerable Adults. Water damage to celings and the rippled carpet should be made good. The flat roof should be checked to limit any risk of future damage inside the home. Older items of upholstered furniture should be checked for fire retardancy and replaced if necessary. The bathroom discussed at inspection should be redecorated. A copy of the current insurance schedule should be forwarded to the Commission. Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 21 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Woodlands J51J01_s6241_woodlands_v243818_100805.doc Version 1.40 Page 22 - 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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