Inspection on 11/01/06 for Woodlands

This inspection was carried out on 11th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodlands 22/10/08

Woodlands 02/11/06

Woodlands 26/07/05

Woodlands 23/03/05

Woodlands 04/06/04

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

CARE HOMES FOR OLDER PEOPLE Woodlands Riverhead Driffield East Yorkshire YO25 7PB Lead Inspector Jean Dobbin Unannounced Inspection 11th January 2006 10:20 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 DS0000019774.V274241.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. Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodlands Address Riverhead Driffield East Yorkshire YO25 7PB 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) 01377 253485 01377 255287 Humberside Independent Care Association Limited Mrs Nicola Jane Wise Care Home 56 Category(ies) of Dementia - over 65 years of age (56), Old age, registration, with number not falling within any other category (56) of places Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: Woodlands is a purpose built home constructed in the 1970’s. It is situated less than 5 minutes walk from the centre of Driffield and local transport links. The home has service user bedrooms on both levels and a vertical passenger lift to access the first floor. Woodlands provides personal and social care for 56 residents over the age of 65, a proportion of whom have dementia and there are close links with the community nursing and mental health teams. An activities coordinator ensures that there is a range of recreational opportunities and entertainment available, both within and away from the home. There are car parking facilities on site. Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This summary relates to an unannounced visit on Wednesday 11th January 2006. The inspection lasted six hours including preparation time. The manager was present for the whole of the visit. There was the opportunity to examine some residents’ files and look at how those residents’ needs are assessed. Policy and staffing documents were also looked at, as well as the home’s accident record book and complaints file. The systems in place to safeguard the residents’ monies were also examined. There was a tour of the home and the opportunity to observe carers interacting with residents, both in a caring situation and at lunchtime. Much of the time was spent talking with residents, two carers and a visiting district nurse There is an outstanding complaint, which is being investigated and managed at a senior level. The Commission for Social Care Inspection is not involved in this investigation. What the service does well: What has improved since the last inspection? Recruitment of permanent staff means there is no longer a reliance on shortterm agency cover. This has enabled better planning of training programmes as well as improved team morale. Residents have benefited by being cared for by committed and familiar staff, who understand their needs. The building and decoration work in the foyer is completed to provide a bright and open area, providing an improved environment for the residents. There has been further work developing menu choices and there are now healthy options, which has led to the home being given a ‘heartbeat award’ for healthy eating. Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 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. Woodlands DS0000019774.V274241.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 Woodlands DS0000019774.V274241.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): None EVIDENCE: Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 The residents have a comprehensive assessment plan in place and their personal, social and health care needs are met. EVIDENCE: The care plans of four service users were examined. One of these has lived in Woodlands for less than four weeks. The documentation belonging to the three ‘older’ residents are individualised and show good understanding of the residents’ personal and social needs, which are reviewed regularly. There are risk assessments in place, with clear guidelines to aid the planning process and ensure a consistent approach. Residents can be assured that their plan of care accurately reflects their needs. The documentation for the newest resident, however, relies on the pre admission assessment to determine their needs, whilst a more detailed plan is constructed, within a timescale determined by the home’s policy. In this instance though, the resident suffered an ‘unforeseen event’ in the days following their admission. Written risk assessments are not yet in place. The management team within the home should apply their policy flexibly and provide more urgent assessment plans when necessary. This will ensure that all staff are aware of residents’ needs Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 10 and reassure those residents and their families that their changing needs are recognised and acknowledged. The care plans examined clearly documented the support and guidance provided from other health care professionals. The community nurse confirmed the close links and described the staff at Woodlands as being “very on the ball”. She felt the home was very well run and she trusted their judgement, when they requested advice. A chiropodist visits the home regularly. Residents can be sure that their health needs will be cared for. Woodlands DS0000019774.V274241.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): 15 The residents receive a balanced and varied diet, with alternative choices available at each meal EVIDENCE: Residents spoken with all said that there had been an improvement in the quality of the meals over recent months, and were generally very complementary about the food, the menu choices and the portion sizes. The home has recently won a ‘heartbeat award’ for its healthy eating menu. There is a vegetarian option at each meal and according to the menu; salads and omelettes are available as alternatives each day. The menu, however, is not displayed and one resident suggested that sandwiches would be provided if the main meal options were not to your liking. There are two dining areas with linen tablecloths and napkins. There were gravy boats on the table. The meals were served in a respectful manner. Staff were seen assisting residents with their meals in a relaxed and unhurried way, however carers feeding residents meant that there appeared to be few remaining staff to help the rest of the diners. One resident complained that their meal was cold, and the meat had not been cut up. This person received a courteous apology and the carer immediately got another meal for them. Whilst residents can be satisfied that high quality food is provided, staff must ensure that good standards are maintained at all times. For example one frail resident was being assisted with their meal in one of the lounges whilst a housekeeper was also, close by, cleaning the lounge furniture with spray polish. Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 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 the following standard(s): 16,18 Residents have confidence that a complaint will be taken seriously and acted upon; and that carers will ensure that residents are protected from any type of abuse. EVIDENCE: There is a complaints policy at Woodlands and those residents spoken with were very clear about whom they should talk with if they had any concerns. All felt confident that their views would be acknowledged and acted upon. There has been one complaint recorded since the last inspection and this was investigated, leading to a satisfactory outcome, within the policy timescale. There is an outstanding complaint, whose investigation is being managed at a more senior level. The staff spoken with confirmed that they had received training on adult protection and were able to describe different types of abuse. They also understood their responsibility should an alleged abuse take place. Residents can be reassured that staff are alert to any kind of neglect. Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 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 the following standard(s): 26 Residents live in a clean and tidy home, which is free from odours. EVIDENCE: Woodlands provides a clean light environment for its residents. The decoration is in good order apart from the first floor corridor, which requires some attention. There was no evidence, on walking around the home, of any soiled articles being handled inappropriately. Residents spoken with were happy that staff washed their hands properly, when providing personal care. There was no evidence of any unpleasant odours. Residents can feel confident that their welfare is protected, as far as possible, by good practice. Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 14 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 Residents can be reassured that their personal and social care needs can be met by the numbers of staff on duty. EVIDENCE: After a difficult period with staff vacancies, Woodlands has almost filled all its positions. There is one carer awaiting mandatory checks prior to starting work, and the home have received applications for the final vacancy. Those staff members spoken with are aware of their role within the home and feel that there is currently enough staff to meet the residents’ personal needs. Staff were seen reading and writing in the care plans, which should enable them to have good understanding of individual needs. The policy at Woodlands is for the key worker to support their resident in carrying out personal care and bathing, and a full staff complement should enable that good practice to continue. Residents spoken with said that they did not have a key worker, however they did have a “special carer”. Residents can receive consistent support from carers who are aware of their individual needs. Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 15 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): 33,35,38 Residents at Woodlands can be reassured that their views and opinions matter when determining best practise and that their finances are managed responsibly. EVIDENCE: The home has robust systems in place to monitor the quality of the service they provide. These include regular residents’ meetings and also residents’ surveys where individual views can be sought and discussed. Residents’ also commented that they felt comfortable talking to the manager “anytime”. Residents can feel confident that their views are valued and that they can influence any decisions about the running of the home, which the management team might make. The home encourages the resident and their relatives to retain responsibility for their financial affairs. Whilst Regulation requires that residents’ personal allowances are not pooled, at Woodlands there is one combined account where each resident has an individual ‘account’ of spending money, and all transactions are receipted and recorded. Statements are available for the Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 16 resident or their family as requested. Two people check this pooled money twice a day. Residents who have no family support have an individual, named bank account. Service users can be reassured that their finances are being managed responsibly, however individual monies should be kept separate from each other. Standard 38 was not fully inspected but it was noted, on walking round the home, that one of the service rooms with unregulated hot water was easily accessible by residents. This needs to be addressed to ensure residents are not put at risk from very hot water. Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 1 Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 18 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 OP38 Regulation 13 (4)(c) Requirement Rooms with unregulated hot water must have a device on the door to prevent access by residents. Timescale for action 28/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP26 OP28 OP35 Good Practice Recommendations The first floor corridors and doorways need repainting The management team should continue to support training to NVQ Level 2 in Care, for the care assistants. It is recommended that residents’ monies be not kept all together in a pooled amount. Woodlands DS0000019774.V274241.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000019774.V274241.R01.S.doc Version 5.1 Page 20 - 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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