Inspection on 10/07/06 for Woodlands

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 26/07/07

Woodlands 27/07/05

Woodlands 13/04/05

Woodlands 02/11/04

Woodlands 10/05/04

Woodlands 15/09/03

Woodlands 10/06/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Woodlands 84 Long Lane Ickenham Middlesex UB7 7UG Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 10th July 2006 10:50 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 Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 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. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Address 84 Long Lane Ickenham Middlesex UB7 7UG 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) 01895 634 830 01895 624 887 campbell11243@hotmail.co.uk Mrs Sybil Agatha Rose Ms Marcia Loren Patterson-James Ms Marcia Loren Patterson-James Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2005 Brief Description of the Service: Woodlands is a care home which is registered for twenty - one older people. The home is located on a busy main road between Ickenham and Hillingdon. The nearest shops are at Ickenham High Road, situated about one mile away. Ickenham and Hillingdon Underground Stations are within walking distances. The home is privately owned. There are fourteen bedrooms. Eight single and six double. There is a large lounge/dining room, which accommodates all service users at any one time. There is a small ground floor room, formerly an office, which is now designated a meeting/visitors room. There are three bathrooms. One has a Parker bath. This room also has a shower. There are two bathrooms without any specialist appliances. One bathroom is used additionally for hairdressing. The kitchen and laundry room are on the ground floor. There is a small room where staff have lockers and can store their clothing. There are no further staff facilities. The Registered Manager is one of two Providers. There is a team of day and night staff. Three staff are on each shift during the day and there are two waking night staff. There is a cook and a domestic worker. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken over a period of one day. A total of 7 hours were spent on the inspection process. The Inspector carried out a tour of the home, and inspected service user plans, maintenance records, training records and staff files. A number of service users, 4 staff and the two Registered Providers were spoken with as part of the inspection process. At the time of inspection there were 19 service users accommodated at the home. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. What the service does well: What has improved since the last inspection? What they could do better: Pre-admission assessments must be fully completed, dated and signed. Where a service user does not fall within the homes category of registration then the needs of this service user must be reassessed. Although there has been an improvement in the service user plans, continued work is required to attain and maintain a consistent good standard in this area. A full health & safety audit of the home needs to be undertaken and an action plan to address the shortfalls identified drawn up and implemented. This must include issues with the environment and the furniture within the home. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 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 DS0000027081.V300777.R01.S.doc Version 5.2 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 Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 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): 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are undertaken, these were not always fully complete, thus staff would not always be able to ascertain if the home is able to meet the prospective service users needs. EVIDENCE: The Deputy Care Manager stated that most referrals are received via a Social Worker. The home obtains a copy of the Needs Led Assessment completed by the Social Worker. Once this has been received the potential service user is assessed by the Deputy Care Manager for their suitability for the home. The home has in place their own pre-admission assessment documentation. Samples of this were seen on two of the service users files. One pre-admission assessment had been completed in full and the second pre-admission assessment viewed was incomplete and had not been dated or signed. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 9 Records viewed for one newly admitted service user indicated that they had a dementia type illness. Woodlands Care Home is not registered to accommodate service users with dementia. The Inspector discussed the need for this service users needs to be reassessed by the placing Social Worker as a matter of priority. A Variation in Registration would be required if the home continued to accommodate the service user. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in the outcome area in relation to service users plans is adequate. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. (Standards 8,9 and 10)This judgement has been made using available evidence including a visit to the service. The service user plans are in place. Updates do not always take place and assessed needs are not always clearly identified. Thus staff do not always have the information required to meet the service users needs. Service users health and medication needs are being met. Staff are courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy, dignity and independence. EVIDENCE: The home has in place a system for care planning. Two service user plans were viewed by the Inspector. One was found to be complete and contained Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 11 information on how to meet the identified needs of the service user. There was evidence of this service user plan being reviewed monthly. The second care plan viewed for a service user who had recently been admitted to the home. The service users needs had not been identified and it was not clear how the service user was to be cared for by the staff. The Deputy Care Manager agreed that he would undertake an audit of all the service user plans, identify any shortfalls and have in place an action plan on how these shortfalls were to be addressed. The Deputy Care Manager also agreed that all care staff would receive further training in this area. Moving and handling, falls risk assessments, nutritional assessments, skin assessments and mental health assessments were available. For one service user these had been reviewed, for the other service user these had not been reviewed. Records viewed evidenced that service users have access to specialist medical, nursing, dental, chiropody and services from the Primary Care Trust and local hospitals. The pre-inspection questionnaire indicated that a policy and procedure on the administration of medication was available. The home uses the Boots Monitored Dosage System. Medication Administration Records viewed had been fully completed. Care staff working in the home undertake the Boots self train programme. The Deputy Care Manager stated that only senior Care staff administer medication. The GP for the home had recently undertaken a medication review for all service users. Medication viewed was appropriately stored and dates of opening had been recoded on liquid medications. Staff were heard to speak with service users in a gentle and courteous manner. At the time of inspection service users were being treated with dignity and respect. Service users spoken with expressed their satisfaction with the home and said that they are well cared for. Double bedrooms viewed had hospital type screens in place. All bathrooms and toilets are lockable. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Information regarding service users interests is available and activities are provided to meet the service users needs. Service users rights are respected and advocacy services can be arranged to provide independent representation for service users. Food choices are available and service users dietary needs are catered for, to include meeting any specialist dietary needs or requests. EVIDENCE: Service users who spoke with the Inspector confirmed that daily routines are flexible. This included times that they got up and went to bed. The care staff within the home undertake social activities. Service users confirmed that day trips are arranged and that they enjoyed these. Information on activities was available. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 13 The home has in place an open visiting policy. Service users confirmed that their visitors are able to see them in their bedrooms or in the lounge area. Service users also go to see their family and friends outside of the home. Information on local advocacy groups was available. At the time of the inspection none of the current service users had an independent advocate. A four weekly menu was in place and this was viewed by the Inspector. Any changes to the menu are recorded. The service users who spoke with the Inspector confirmed that they enjoyed the food provided and that an alternative meal was available. Drinks and snacks are served to service users throughout the day. The kitchen was viewed and found to be clean and well ordered. Records viewed were up to date. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The systems for managing complaints and adult protection matters are robust, thus safeguarding service users. EVIDENCE: A complaints policy and procedure were available. The home had received one complaint in the last twelve months and this had been investigated and any shortfalls addressed. The Commission has received no complaints. The Deputy Care Manager stated that Protection of Vulnerable Adults training had taken place in August 2005 and the Safeguarding Adults Coordinator for Hillingdon Social Services had provided this training. The Deputy Manager stated that the Adult Protection procedure had been reviewed to provide clearer guidance to staff. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 15 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): 19,20,22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Generally the environment is in good condition, thus providing service users with a homely environment to live in. Shortfalls identified should be easy to address. EVIDENCE: The inspector undertook a tour of the premises. Generally the home was being maintained. Bedrooms viewed were clean and hygienic. The rear garden was well maintained and a seating area is available for the service users to use. The need to have a renewal and redecoration plan was discussed with the Deputy Care Manager. The home has a large lounge/dining area on the ground floor. Some of the seating was either worn or had been damaged exposing the foam filling underneath. The carpet between the small lounge and the toilet had lifted and Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 16 was a potential trip hazard. Bedrooms are redecorated when they become vacant. It was not clear whether a renewal and redecoration plan was in place. The home has one passenger lift. Suitable aids and adaptations were seen throughout the home. A call bell system is in place. Bathrooms and toilet areas viewed were clean and hygienic. Soap, gloves and paper towels were available. The laundry was not viewed at this inspection. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. These judgements have been made using available evidence including a visit to the service. The home is appropriately staffed to meet the current needs of the service users. Staff training in the home provides staff with the skills and knowledge to meet service user’s needs. Robust systems are in place for the recruitment of staff, thus safeguarding service users. Shortfalls identified should be easy to address. EVIDENCE: The home had 19 service users accommodated at the time of the inspection. The Deputy Care Manager stated that on the morning shift there are a minimum of three care staff during the day and that there are two waking night staff at all times. In addition to this there is a cook and a domestic on duty. Staffing is kept under review and this was discussed with the Registered Manager. The induction and foundation training programmes meet the Skills for Care (formerly TOPSS) core standards. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 18 The Deputy Care Manager stated that there is an NVQ training programme in place and that 5 staff members have completed their NVQ and that another 5 staff members have been enrolled to undertake this training. Since the last inspection the Deputy Care Manager stated that he had audited the staff employment files. Two staff employment files were viewed. Generally both files contained the required information. One shortfall was identified with one file where the staff member’s application form could not be located. No other shortfalls were identified. There was evidence that staff were receiving training. A programme of training was in place. A training matrix submitted with the pre-inspection questionnaire detailed the training that had been undertaken by care staff. The Deputy Care Manager confirmed that all staff have been issued with a copy of the General Social Care Council codes of conduct and practice. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality in the outcome area in relation to service users monies is adequate. This judgement has been made using available evidence including a visit to this service. The views of service users and their representatives are sought. The system of maintaining service users personal allowances is unsatisfactory and needs to be robust to ensure service users interests are safeguarded. Health & Safety systems are in place in the home and ensure the safety of the service users, staff and visitors to the home is maintained at all times. EVIDENCE: Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 20 Service users/representatives/staff and stakeholders satisfaction questionnaires had been completed, and the Deputy Care Manager was in the process of collating the results of the surveys. The home must ensure that the CSCI receives a copy of any such survey results. A written plan was available of the work that the home was planning to undertake in relation to quality assurance. Further work is required in this area to include developing auditing systems for medication, care planning, environment and health and safety. Six weekly staff meetings are held and minutes were viewed. Service users meetings are held and minutes of these meetings were available. Small amounts of service users personal monies are held securely by the home, and a running balance with receipts is maintained. Samples of service users personal monies records were viewed. The Inspector was informed that personal allowance monies are kept in the homes business account. The need to have a separate account for service users monies was discussed with the Deputy Care Manager. Staff supervision records were available and staff were receiving regular supervision from the Deputy Care Manager. Servicing and maintenance records were sampled. The maintenance records were viewed and overall these were up to date. Fire alarm tests and fire drills were being carried out. A fire risk assessment was in place. Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X x 2 x x x 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 x 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 2 3 x 3 Woodlands DS0000027081.V300777.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 14(1) Requirement Timescale for action 30/09/06 2. OP3 14(1)(2) The pre-admission assessments undertaken by the home must be completed in full, dated and signed. Where service users needs do 30/09/06 not fall within the category of registration for the home, the needs of this service user must be reassessed. If the home can meet the service users needs then an application for a Variation in Registration must be completed and sent to the CSCI. Service user plans and moving and handling assessments must clearly identify the needs of the service user. Monthly reviews must take place and the service user plan must be update following the review. An audit to identify the redecoration and refurbishment needs of the home must be carried out. This must include furniture and fittings.An action plan must be drawn up to address the findings, with DS0000027081.V300777.R01.S.doc 3. OP7 OP8 15 17(3) 30/09/06 4. OP19 23(2) b 30/09/06 Woodlands Version 5.2 Page 23 5. OP20 23(2) b 16(2) c timescales for completion. A copy of the action plan must be sent to the CSCI. Armchairs which are damaged or not safe must be replaced. The carpet inbetween the small lounge and the toilets must be made safe. Staff employment records must contain all the required information as detailed in Schedule 2 of the Care Homes Regulations 2001. Information obtained from service users questionnaires must be collated and published. Systems must be in place for the auditing of the home. Where service users monies are managed by the home, these must be kept in an account separate from the homes business account. 30/09/06 6. OP29 Schedule 2, 19 04/09/06 7. OP33 24 30/09/06 8. OP35 20(1)b 30/09/06 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 DS0000027081.V300777.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 DS0000027081.V300777.R01.S.doc Version 5.2 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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