Inspection on 27/07/05 for Woodlands

This inspection was carried out on 27th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodlands 26/07/07

Woodlands 10/07/06

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 Gavin Thomas Unannounced 27 July 2005 at 10.10am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodlands Address 84 Long Lane, Ickenham, Middlesex UB7 7UG 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) 01895 634 830 01895 624 887 LYDIAGATHOGO@AOL.COM Mrs Sybil Agatha Rose 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 G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13 & 18 April 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 G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over six hours. A substantial amount of time was spent assessing the home’s performance in meeting requirements set at the previous inspection. The Inspector spoke in length with two service users. Both service users said they were well and like the home. One service user said that they had recently moved to the home. The service user described the staff as being caring and nice. The service user also said that although they enjoyed the food, they would like more cultural foods from time to time. The Inspector referred this to the Assistant Manager to take forward. The service user also said that they would like to meet with their visitors in private. This was also referred to the Assistant Manager to ensure that the service user is offered a private room to entertain visitors. All service users were well dressed and appeared to be relaxed and comfortable. Mid morning drinks were being served upon arrival. This was followed by an indoor ball game. Some service users had chosen to listen to music and two service users chose to read instead. The home was clean and well presented throughout. Staffing levels were maintained with three care staff on duty, one of whom was the shift leader. What the service does well: The home continues to maintain a stable staff team. The home has very few staff vacancies. Evidence examined indicated that both the Assistant Manager and Deputy Manager are making good progress in raising standards and developing current systems. The home provides a welcoming and comfortable environment. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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 G61-G10 s27081 Woodlands v214232 270705 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 Woodlands G61-G10 s27081 Woodlands v214232 270705 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) 1, 3 & 5 The home has produced a detailed Statement of Purpose and Service User Guide. The Service User Guide should be kept under review to ensure that the current format is suitable for intended Service Users. Good systems were in place for the assessment of prospective service users. Minor requirements are required for quality control purposes. EVIDENCE: A Statement of Purpose and Service User Guide were in place. Both documents were very informative. All service users were in receipt of a copy of the Service User Guide. The Statement of Purpose was being updated at the time of this inspection. A referral and assessment process was in place. Completed assessments seen were detailed. However, this record must be signed and dated by the person conducting the assessment. The assessment record must also indicate if the Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 9 home could offer a prospective service user a placement based on their assessed needs. All prospective service users are informed in writing of the outcome of their assessment. The Deputy Manager confirmed that social work assessments are obtained from Placing Authorities for all prospective service users. An admissions process was in place. The admissions process varies in accordance with the needs and wishes of the prospective service user. All prospective service users and where possible, their relatives, are invited to visit the home prior to admission. This home does not provide an intermediate care service. Therefore, standard 6 of the National Minimum Standards for Care Homes for Older People was not assessed. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 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 standard(s) 7 & 9 Good progress was being made to improve the quality of care plans. The medication at this home is well managed. EVIDENCE: Care plans were in place for all service users. New care planning methodology was being introduced. The new care plans were being devised with input from service users and where possible, their relatives. The new care plans examined were judged to be of good quality. The Deputy Manager was responsible for coordinating the new care planning system. A policy on the management and administration of medication was in place. This is not a registered care home with nursing provisions. Therefore, the senior person referred to in the medication policy as “ First Registered Nurse”, must be removed and replaced with the appropriate job titles of staff approved for administering medication. Routine pharmaceutical audits are carried out. The most recent audit was carried out in May 2005. The Inspector saw a report for this visit. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 11 Medications are stored in a portable locked trolley. When not in use, this trolley is secured to the wall for safety reasons. One service user was insulin dependent. The Deputy Manager said that District Nurses visit the home to administer insulin to the service user. The home was using the MDS (Monitoring Dosage System) for the dispensing of medications. It was noted that one Medication Administration Record was not fully completed. Medication Administration Records must be completed properly at all times. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 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 standard(s) 14 & 15 The home does well promoting good practice regarding service users’ personal affairs. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The home is registered under the Data Protection Act 1998. A valid registration certificate was in place. The Assistant Manager said that the home does not manage service users finances. Relatives or placing authorities are responsible for service users finances. Service users may deposit monies in the home’ s safe for safety reasons. Individual records are kept of finances held on behalf of service users for safekeeping. None of the current service users had an independent advocate. The Assistant Manager confirmed that all service users and their relatives have been given details of appropriate advocacy groups. A four weekly menu was in place. The Registered Manager said that service users are given the opportunity to contribute towards the menu. Records are kept of food served to service users. These records were well maintained and included any changes to the menu. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 13 Three service users spoken to said that they enjoyed the food and the portions were adequate. One service user recently admitted to the home, said they would like bacon and cabbage from time to time. This is not currently included on the menu. The Inspector referred this request to the Assistant Manager. Service users may prepare drinks and light snacks independently if it is safe for them to do so. Drinks and snacks are served to service users throughout the day. Main meals are served at the following times: Breakfast – 8.30am – 9.30am Lunch – 12noon – 1pm Tea – 5pm – 5.30pm Supper – 7pm Lunch served on the day of this inspection was pot roast pork, fresh vegetables and potatoes. Service users had the choice of an alternate meal. The Inspector sampled lunch. The food was very well cooked and appetising. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 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 standard(s) 16 &18 The homes procedures for managing complaints were satisfactory. The adult protection policy and procedure contained relevant information but further details would make staff aware of the correct procedures to be followed in the event of suspected or known abuse. EVIDENCE: A complaints policy and procedure was in place. The complaints procedure has been updated since the last inspection. The procedure now includes the contact details for the home and the CSCI. A complaints record has now been devised and implemented. The home was advised to add a section to this record indicating if a complaint is upheld or not. An adult protection policy and procedure was in place. The procedure for responding to incidents of adult protection must still be updated to include procedural guidance for responding to suspected or known abuse. This remains outstanding from the previous inspection. Adult protection training for the staff team has been scheduled for September 2005. The Assistant Manager and Deputy Manager said there were no known concerns regarding service users’ safety or protection. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 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 standard(s) 20 & 22 Although the grounds of home were generally well kept, some of the paving slabs and one of the ramps were judged to be a potential safety hazard. EVIDENCE: All communal rooms are provided on the ground floor. The home has a lounge/dining room. Lighting is domestic in character. Seating was judged to be of good quality. The rear garden is enclosed and well kept. Outdoor provisions include a decking area and lawn. Some of the paving slabs in the rear garden were uneven and judged to be a potential safety hazard. The side of the ramp leading from the dining room door was also judged to be a potential safety hazard. The Assistant Manager was required to risk assess these areas and for appropriate action to be taken to make these areas safe. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 16 Subsequent to this inspection, the Assistant Manager informed the CSCI that three building firms have visited the home to assess the paving slabs and the ramp. The home was waiting for quotations from these building firms. The Assistant Manager stated that until such time when work has been carried out to make safe the uneven paving slabs and the side of the ramp, service users would be accompanied by staff when they access the rear garden. Adapted facilities are provided in accordance with service users assessed needs. Commodes are provided in all service users bedrooms. Handrails are installed in all corridors. Grab rails are positioned near the toilets. The home has one parker bath. A chair lift is also provided in another bath. A portable hoist is used throughout the home. A lift is available for access to the first floor. A call system is installed in all bedrooms, bathrooms and toilets. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 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 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) 29 & 30 The home maintains staffing levels in accordance with the needs of the service users. Evidence of recruitment checks for some of the current staff team was still poor. This must improve to demonstrate the fitness of all staff appointed. EVIDENCE: A recruitment policy and procedure was in place. Seven staff personnel files were examined for the purpose of this inspection. Staff files had improved since the last inspection. However, evidence of specific recruitment checks including references and health declarations was not available on some files examined. As a result, the home must carry out a further audit on all staff files to ensure that recruitment checks are in keeping with the criteria as set out in Schedule 2 of the Care Homes Regulations 2001. This requirement has not been fully met from the previous inspection. At the previous inspection, the home was required to obtain updated information on the employment status for some staff who are non – UK passport holders. This had not been fully achieved. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 18 The home must obtain copies of the codes of conduct and practice as issued by the General Social Care Council. The codes of conduct must be distributed to the staff team. A training schedule for the period 2004 -2005 was in place. Records were kept of “actual” training attended by the staff team. Induction and foundation training modules were in place. There had been some improvement in the quality and content of staff training profiles since the last inspection. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34 & 36 Interim management arrangements must be stabilised until such time when the Registered Manager returns to work. The home must continue making progress towards the implementation of quality assurance and monitoring systems. The home was doing well in updating the recording systems for financial and accounting procedures. EVIDENCE: The Registered Manager was on long-term sick leave at the time of this inspection. The Assistant Manager and the Deputy Manager were responsible for the day-to-day running of the home. The home was also in the process of looking into alternate management arrangements until such time when the Registered Manager returns to work. The home is required to continue keeping the CSCI informed of interim management arrangements. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 20 Quality assurance and monitoring systems were not in place. Surveys had been devised. The home was in the process of distributing these to service users and their relatives. The Deputy Manager was in the process of devising a quality assurance framework. An extended timescale was agreed by the Inspector for the home to fully implement these systems. The Assistant Manager said that the home was financially viable. The Assistant Manager did explain that the home was owed a substantial amount of money for unpaid placement fees. The Assistant Manager was in the process of negotiating the payment of unpaid fees with the Placing Authority. Financial and accounting procedures were in place. The Assistant Manager said that he was in the process of putting accounts details for the current financial year on to electronic software. The Assistant Manager stated that he was in the process of devising a business and financial plan on the new software package. A valid employers liability insurance policy was in place. A valid building and contents insurance policy was also in place. All staff currently receive formal supervision every three months. In accordance with standard 36.2 of the National Minimum Standards for Care Homes for Older People, care staff should receive formal supervision at least six times a year. Therefore, the frequency of staff supervisions must increase to every two months. Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION x 2 x 3 x x x x STAFFING Standard No Score 27 x 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x x 3 x 2 x x Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14-(1)(a) Requirement The intial assessment record must include a section to be signed and dated by the person conducting the assessment. This record must also indicate if the home could offer a prospective service user a placement based on their assessed needs. The senior person referred to in the medication policy as “ First Registered Nurse”, must be removed and replaced with the appropriate job titles of staff approved for administering medication. Medication Administration Records must be completed properly at all times. A section must be added to the record of complaints indicating if a complaint is upheld or not. The adult protection procedure must be updated to include further guidance for staff to follow in the event of suspected or known abuse. (Timescale of 30/6/05 Not Met). The home must obtain copies of the codes of conduct and practice as issued by the General Timescale for action 30/9/05 2. 9 13-(2) 30/9/05 3. 4. 9 16 13-(2) 17(2) Schedule 4-11 13(6) 31/8/05 30/9/05 5. 18 30/9/05 6. 29 18-(1)(a) 30/9/05 Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 23 7. 29 19 Schedule 2 8. 33 24 9. 36 18-(1)(a) Social Care Council. The codes of conduct must be distributed to the staff team. All current staff files must be brought up to date and in keeping with the required checks as stated in Schedule 2 of the Care Homes Regulations 2001. (Timescale of 31/5/05 Not Met). A full quality assurance system including an annual development plan must be devised and implemented. (Timescale of 31/7/05 Not Met). The frequency of staff supervisions must increase to every two months. 30/9/05 31/10/05 30/9/05 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. Refer to Standard Good Practice Recommendations Woodlands G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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 G61-G10 s27081 Woodlands v214232 270705 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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