Inspection on 02/11/06 for Woodlands

This inspection was carried out on 2nd November 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 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 11/01/06

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 Rob Padwick Unannounced Inspection 12:30 2 November 2006 nd 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.V317671.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 DS0000019774.V317671.R01.S.doc Version 5.2 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.V317671.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2006 Brief Description of the Service: Woodlands provides personal and social care for 56 residents over the age of 65, some of whom have dementia. There are close links with the community nursing and mental health teams. Woodlands is a purpose built home and was constructed in the 1970’s. The home is situated less than 5 minutes walk from the centre of Driffield and its transport links. Accommodation is provided on two levels with a passenger lift allowing access to the first floor. There are car parking facilities on site. The home is owned and operated by Humberside Independent Care Association Ltd. (HICA) which is a not for profit organisation. The standard fees charged by the home range from £ 328.80 to £440 with additional charges made for hairdressing, chiropody, toiletries etc. Woodlands provides information about the home to service users in its Statement of Purpose and Service User Guide. Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A Pre Inspection Questionnaire asking for information about home was sent out before this visit and information from this was used as part of the inspection process for this service. Other information that was used included reports from monthly visits carried by a senior manager from the parent company and notifications sent to the Commission for Social Care Inspection about serious incidents that had taken place in the home. Questionnaires were sent out to relatives and Health and Social Services professionals associated with the home. Seven replies were received from the group of relatives who were contacted and two of these expressed some concerns about the staffing levels in the home, although these could not be substantiated on the occasion of this visit. Two comment cards were returned from professionals associated with the home and these expressed satisfaction with the home. This unannounced visit lasted for 7 hours and during this time a tour of the building was carried out and time was spent talking with service users and seeing how they lived. Other time was spent checking the outstanding requirements and recommendations from previous inspections, reading the residents’ files and talking to staff. What the service does well: What has improved since the last inspection? Action had been taken to implement the requirements and recommendations from the previous inspection and in order to ensure that the residents were kept safe; measures had been taken to ensure they were unable to have access to rooms with unregulated hot water. Updated information about the home had been given to residents, in order to ensure that they were kept informed about changes that affected them. The residents’ environment was being maintained with improvements made when these became necessary. Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Woodlands DS0000019774.V317671.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 DS0000019774.V317671.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents had been assessed in order to ensure that the service could meet their needs and they had been given information about the home, in order that they could make an informed choice about moving into it. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents indicated that they had been involved in decisions about moving into the home. Case files contained copies of assessments, which had been carried out of the individual residents, in order to ensure that the home could meet their needs. The case files examined contained copies of recent information which had been issued to residents, in order to ensure that they and their representatives were kept informed about any changes concerning the home that had been made. Woodlands does not admit service users for intermediate care Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. The health and personal care needs of the residents were being sensitively met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three residents’ files inspected, contained copies of personal support plans that had been developed, in order to guide staff in meeting the resident’s individual care needs. Daily recordings were included in these, together with assessments of resident’s known areas of risk. Support plans had been reviewed by the commissioning authorities as required, but no evidence was seen that staff in the home had reviewed or amended the support plans inspected on a regular basis, and a recommendation is made in this matter. Residents confirmed that their health and personal care needs were being met and case files contained evidence of appropriate monitoring of the residents’ conditions. Two District Nurses that were visiting commented that staff worked closely with them and that they had “ no concerns about the home”. Staff were observed to be sensitive and caring in their approach to working with the residents and inspection of the home’s accident book and reports Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 Page 10 submitted to the Commission, indicated that relevant procedures were being followed, in order to ensure that the health needs of the residents were met. Residents confirmed that they were treated with respect and that staff observed their rights to privacy, as required. The home had policies and procedures, in order to safeguard the residents, in respect of medication. Information supplied by the manager as part of the inspection process indicated that staff responsible for administration of medicine had received training in this. Staff spoken to were confident and knowledgeable about this aspect of their practice and observation of a medication round confirmed that procedures were being followed appropriately. Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. The residents’ were being treated with dignity and respect and their social needs were being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents confirmed that they were able to take part in various social activities, which had included a Halloween party the previous week. Residents were observed contentedly chatting with others or doing “their own thing” and discussion with them indicated that some attend an access group at a local day centre. A hairdresser and local church minister visit on a regular basis and trips out are also organised. Relatives commented that they were welcomed into the home and that they are invited to take part in Christmas events, which include a special Christmas meal that is held in the home. Residents spoke fondly of the home’s activities organiser who had recently left, and a recommendation is made that she is replaced in order to ensure that the social, emotional and psychological wellbeing of the residents continue to be addressed. Residents commented that the food was good and that alternative choices were always available should they not like the main meal on offer. The home has achieved a “heartbeat” award for its meals and inspection of the menus Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 Page 12 confirmed that they were of a nutritious and balanced nature. Case files inspected contained copies of nutritional assessments, together with evidence of individual residents’ weights being monitored appropriately. Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The residents were being safeguarded from abuse and concerns and complaints raised by them were being taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints policy and procedure that both residents and visiting relatives indicated confidence in using. The complaints log contained six complaints that had been made since the last inspection, together with evidence to demonstrate that appropriate action had been taken to resolve these. However a follow up contact from a relative who wished to remain anonymous, indicated a slight level of reluctance in fully using the complaints policy, for concern that issues raised might be seen in a negative light. A recommendation is made in these matters. Policies and procedures were available in order to safeguard the residents from abuse. The home’s training log indicated that a course about the dementia needs of residents was due to be given to some staff in the near future and that the protection of vulnerable adults was covered as part of the staff induction process. Staff spoken with indicated that they would take appropriate action in this respect, should they have any concerns. A random check of the residents’ money held by the home on their behalf was satisfactory. Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The residents’ environment was safe and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was bright, airy and comfortable, with a relaxed and contented atmosphere throughout. Aids and adaptations had been provided to assist the residents and up to date certificates of a random selection of health and safety issues, confirmed that this aspect of practice was being efficiently carried out. Staff were observed to be busily involved in cleaning various parts of the home and the laundry was neat and tidy. Inspection of the building indicated that it was being appropriately maintained and a random inspection of the maintenance records confirmed that appropriate checks were being carried out. Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. The staff had been safely recruited and had received training to help them do their jobs, in order to meet the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents confirmed that staff were meeting their needs and inspection of the homes rota indicated that despite a significant number of staff leaving since the last inspection, staffing levels were being adequately maintained. Staff were observed taking a friendly and courteous approach to working with residents and discussion with those on duty indicated they were committed to doing their jobs well. The provider organisation has an extensive training programme and induction process that staff must complete, before being allowed to undertake further training and staff confirmed that they had received various elements of this help them do their work. However, information submitted by the manager as part of the inspection process indicated that only 20 of the current staff employed in the home had obtained an NVQ level 2 qualification in care. The previous recommendation in this matter is therefore again repeated. A recruitment policy and procedure was in place to ensure that staff are safe to care for the residents. Staff records contained copies of Criminal Records Bureau checks and two written references and other information to indicate that this procedure was being appropriately followed. Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The home was being well managed in order to ensure that the welfare of residents was safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with residents and feedback received from relatives and professionals indicated that the home was being well run. The manager has obtained her both an NVQ level 4 qualification in care and her Registered Managers Award and discussion with her confirmed that she has substantial experience of working with the service user group accommodated in the home. Staff indicated that she was open in her management approach and inspection of the home’s Quality Assurance systems confirmed that she was monitoring the progress of the home in a consistent and thorough manner. Evidence from regular meetings with both residents and staff confirmed that they had been involved in this process. Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 Page 17 The Provider organisation has implemented a computerised system for the management of the residents’ money and a check of this confirmed that their financial interests were being appropriately safeguarded. Discussion with staff and residents indicated that the health, safety and welfare was being promoted. Action had been taken to implement the previous requirement in order that residents do not have access to rooms with an unregulated hot water supply. Inspection of a random sample of the home’s records confirmed that maintenance procedures were being appropriately followed. Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP7OP7 OP12OP12 Good Practice Recommendations The registered person should ensure that staff review the residents care plans on a monthly basis to ensure that they are kept up to date. The registered person should ensure that a new activities coordinator is appointed, in order to ensure that the social, emotional and psychological wellbeing of the residents continue to be addressed. The registered person should consider amending the home’s complaints policy in order to make it easier to use and reassure residents and their families that complaints are viewed positively. The registered person should continue to support training to ensure that 50 of the care staff have obtained an NVQ Level 2 qualification in care. 3 OP16OP16 4. OP28OP28 Woodlands DS0000019774.V317671.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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