Inspection on 16/06/05 for Woodlands

This inspection was carried out on 16th June 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 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 09/01/08

Woodlands 23/05/06

Woodlands 06/12/05

Woodlands 14/10/04

Woodlands 26/04/04

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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 Christian Head Silver Street Kirkby Stephen Cumbria CA17 4HA Lead Inspector Paula Banham Unannounced 27 April 2005 at 09.50 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. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Christian Head Address Silver Street Kirkby Stephen Cumbria CA17 4HA 017683 71429 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) Cumbria Care Vacant Care Home 33 Category(ies) of DE(E) Dementia - over 65 registration, with number OP - Old age of places Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1.The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 2.The home is registered for a maximum of 33 service users to include:- up to 33 service users in the category of OP (Old age not falling within any other category)- up to 10 service users in the category of DE(E) (Dementia over 65 years of age) 3.Two service users may share a bedroom of at least 16 sqm usable floor space only if they have made a positive choice to do so, and when one of the shared spaces becomes vacant the remaining service user has the opportunity to choose not to share, by moving to a different room if necessary. 4.The staffing levels for the home must meet the Residential Forum Care Staffing Formula for Older Adults. Date of last inspection 17 January 2005 Brief Description of the Service: Christian Head is a residential care home registered with the Commission for Social Care Inspection to provide care and accommodation for up to thirty three people over sixty five years old. Accommodation for service users is provided in four living units, one of which specialises in providing care for people with dementia. The home is owned by Cumbria County County and is carried on by Cumbria Care, a business unit of the County Council. The home is located next to the fire station, close to the centre of Kirkby Stephen. Christian Head is close to local shops and services including doctors surgeries, banks and churches. The home is managed by Mrs Janet Sephton who has applied to the Commission for Social Care Inspection to be the registered manager of the home. Accommodation for service users is provided over two floors in twenty nine single bedrooms and two double bedrooms which two people can choose to share. Three bedrooms have ensuite facilities and there are appropriate toilet and bathing facilities close to all the accommodation provided for service users. The home can only provide accommodation for people who are referred through a social worker and cannot accommodate people who purchase their care privately. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, carried out on 27th April 2005. The inspection focussed on assessing how well the home meets the needs of the people living there. This was assessed by talking to the people living in the home, talking to care staff, examining records held about people and observing activity throughout the home. What the service does well: What has improved since the last inspection? Worn dining furniture has been replaced on two living units which service users said make the dining areas more comfortable. Areas of the home have been re-decorated providing a pleasant and well-maintained environment for people to live in. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 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. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 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 Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 Although people’s needs were known to care staff and were met, there was a failure to follow the admissions procedure properly which had led to one person’s needs not being met. EVIDENCE: The procedure for admitting service users into the home includes an assessment of their needs carried out by their social worker. For all but one person, information from the needs assessments had been used to produce a detailed plan of care needs and preferences. Care staff knew the details of these plans. Service users were complimentary about the staff who supported them and about the care they provided and said they are “well cared for”. An individual plan had not been developed for one person with complex care needs. Care staff said they had been given information about the individual’s needs verbally and that they had read the social worker needs assessment. The service user had made her preferences for the delivery of care known, however, care staff were unaware of this and her needs were not being met. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 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, 9 and 10 The home has a care planning system which, where followed, gives care staff information about the care needs of the people in the home and service users’ needs are met. The system had not been followed for one person and her needs were not met. Service users benefit from safely administered medication. However, staff did not follow the procedures for service users who self-medicated thus placing service users at risk. Service users privacy and dignity are protected and maintained in the home. EVIDENCE: An individual plan of care had been developed for all but one person living in the home. Care staff use the plans to inform them of the person’s preferences and the assistance they require. Service users said care staff “know what I can do myself and what I need help with”. Care staff were able to describe the plans fully and knew how to meet peoples’ needs. Care staff did not know about the needs of the service user for whom no individual plan was in place. The service user had not received care she had requested and her care needs had not been met. Medication administered to service users was handled and recorded properly. Procedures for the self-administration of medication were not followed and the records were inaccurate and misleading. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 10 Care staff were aware of the need to protect service users’ privacy and dignity. Care staff took appropriate actions to maintain service users’ dignity. Service users said that care staff treat them with respect. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14 and 15 Service users exercise control over their lives in the home and the choices and decisions they make are respected. Service users benefit from maintaining contact with people from outside of the home as they wish. The meals provided are appetising, offer choice and variety and provide a balanced diet. EVIDENCE: Service users said friends and relatives visit them in the home and that they choose who they want to see. Staff are aware of the importance of service users receiving social stimulus and emotional support from maintaining contact with their families and friends. Service users said they make choices about their lives including where to see people who visit them, where to have their meals and how they spend their time. Service users said the choices they make are respected. Service users told the inspector the meals provided are “smashing”. Service users said there is “always a choice of meal”. Service users said they enjoy the meals provided. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 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) 18 Service users are protected from abuse by robust procedures and staff knowledge and awareness. EVIDENCE: Care staff are knowledgeable about the home’s procedures for protecting service users from abuse. Care staff said they would refer any concerns about service users’ safety to the manager or one of the supervisors. The supervisors discussed adult protection procedures and are aware of the procedures to follow to ensure that service users are protected from abuse. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 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 and 26 The home was clean and well maintained and provided a safe and homely environment for service users to live in. EVIDENCE: Service users said the arrangement of accommodation into four living units gave them a choice of where to spent their time. The home has a programme for redecoration and on-going maintenance of the property. This maintains a good standard of decoration and ensures the premises are safe for service to live in. New dining furniture had been purchased for two living units. Service users said the new furniture made the dining areas “more comfortable”. Safeguards were in place to protect service users who were at risk if they left the home alone. The home was clean and hygienic and provided a safe and pleasant environment for service users to live in. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 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 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 Care staff provide a high standard of care which takes into account the preferences of individuals and which meets their needs. EVIDENCE: Care staff had received a range of training which was appropriate to their roles. The training had given care staff the skills to provide a high standard of care and to meet the needs of the people living in the home. Service users made a lot of complimentary comments about the care staff who supported them and said they felt comfortable around them. Staff responded to call bells promptly and were friendly and relaxed working with service users. Service users said they received the support they needed, when they needed it and in the way they preferred. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 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 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) 35 and 38 Service users’ money, property and their health and welfare are protected by the systems in place in the home. EVIDENCE: Money and valuables held on behalf of service users are stored securely with records maintained of items held and transactions made on their behalf. The systems followed ensure that service users’ property is kept safely and their financial interests are protected. The systems in place in the home include carrying out spot checks of monies held on behalf of service users. This could be strengthened by including random checks by the home’s manager. Care staff had received a range of training to give them the skills and knowledge to carry out their duties safely and ensured service users’ safety was maintained. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 16 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 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x x 3 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 Standard No 16 17 18 Score x x 3 x x x x 3 x x 3 Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 17 NA 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 7 Regulation 15 Timescale for action The registered person shall, after 29 April consultation with the service 2005 user, or a representative of his, prepare a written plan (the service user plan) as to how the service users needs in respect of his health and welfare are to be met. A service users plan must be prepared for the service user identified at the inspection on 27th April 2005. The registered person shall make 9 May arrangement for the safe 2005 administration of medication. Risks associated with selfmedication must be assessed and appropriate measures taken to protect service users. The registered person shall make 9 May arrangements for the recording 2005 of medication. Service users medication records must include appropriate information about medication which is self administered. Requirement 2. 9 13 3. 9 13 Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 18 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. Refer to Standard 7 35 Good Practice Recommendations Daily records should include the care provided to service users as identified in their service user plan. The systems for handling money on behalf of service users should be strengthened to include spot checks by the manager. Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria, CA11 9BP 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 Christian Head F58-F10 s34975 christian head v218683 270405 stage 4.doc Version 1.30 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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