Inspection on 07/02/06 for Woodlands

This inspection was carried out on 7th February 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 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 25/08/06

Woodlands 10/08/05

Woodlands 30/03/05

Woodlands 27/10/04

Woodlands 04/03/04

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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 Woodlands Woolley Moor House Low Moor Lane Woolley West Yorks WF4 2LW Lead Inspector Patricia Pedley Unannounced Inspection 7th February 2006 11:00 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 DS0000006241.V282982.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 DS0000006241.V282982.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodlands Address Woolley Moor House Low Moor Lane Woolley West Yorks WF4 2LW 01924 830234 01924 830019 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) John & Anne Kelly Anne Kelly, John Noel Kelly Mrs Sandra Goodall Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (27), Old age, not falling within any other category (27), Physical disability over 65 years of age (27) Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: Woodlands is a care home registered for the care of 27 older people some who may have dementia, mental illness, mental disorder and physical disability. The building is set in the beautiful countryside near the village of Woolley on the outskirts of Wakefield. The views from the home are spectacular. It is a two-storey building which is accessible by ramp. The service users have access to all parts of the home by ramp or shaft lift. There is a summer house where residents can sit and enjoy the view. All rooms are single occupancy and have en suite facilities. The service users’ health needs are provided by the local Health Centre and local Hospitals. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home taking place over a 4 hour period. In order to carry out the inspection, a good number of residents were engaged in discussion. The deputy manager and staff spoke with the inspector, records were examined and some of the home was visited including all communal areas and some bedrooms and bathrooms. The inspector would like to take this opportunity to thank residents and staff for their assistance and hospitality shown during this inspection visit. What the service does well: What has improved since the last inspection? What they could do better: Staff records must include all the information required by regulation including a full employment history. Care plans and risk assessments need to be developed further to clearly identify needs and any risk so that staff have a clear understanding how to respond appropriately to meet identified need. Staff would benefit from refresher training on adult abuse and protection and moving and handling. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 6 To ensure fire safety, older furniture needs to be checked for fire retardancy and staff should receive two fire lectures every year. 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 DS0000006241.V282982.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 DS0000006241.V282982.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): 3&5 Residents’ needs are assessed and they are welcome to visit the home to see if they would like to stay. EVIDENCE: The Statement of Purpose and Service User Guide were not examined during this visit. Newer residents spoken with said that they were really pleased to have made the decision to come and stay in the home. They said that they were very happy and had made a number of friends. They said that their family had visited on their behalf before they moved in and had been pleased with what they had seen. Residents’ files included copies of the funding authority’s assessment and care plan. Woodlands DS0000006241.V282982.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 & 10 Residents are more than satisfied that their personal and healthcare needs are met. It would be of benefit to staff to continue with the development of care plans to show what action needs to be taken by staff to meet individually identified needs and how they need to act to minimise risks to residents. EVIDENCE: The deputy manager said that she has started to make changes to care plans. These changes were examined in two care plans. These care plans were found to have been reviewed regularly but some of the changes seen in the review notes had not been transferred on to the current care plan for staff to be made aware. It was also noted that, on the risk assessments, there was information identifying a risk but this had not been evolved into helping form the care plan. Discussion took place how the review notes and risk assessment information could be used more effectively to inform the care plan by identifying individual needs as well as informing staff how they could meet identified needs and how to minimise risks. The deputy manager said that she had a better Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 10 understanding and would address this in each care plan and then let staff know about the changes. There are good records in residents’ files to show that healthcare needs are met through GP and district nurse visits and that other healthcare professionals are consulted regularly. One resident was ill in bed. She was visited and seen to be comfortable, clean and well cared for. Records in residents’ files show that they are weighed regularly. A good number of residents were spoken with. All spoke highly of the care provided. They said that staff attended to their personal care carefully and were very kind. Residents confirmed they could go to bed and get up when they wanted and could make other choices in their daily life. Woodlands DS0000006241.V282982.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): 12, 13, 14 & 15 There are good arrangements for involving service users in regular activities of their choosing. EVIDENCE: A good number of residents were spoken with. They were happy and chatty, both with staff and each other, demonstrating that there was a happy and informal atmosphere in the home. Residents were seen listening to music on their own CD player and drawing. Residents said that they had had a good Christmas and New Year and some had recently been to see Les Miserables at a Barnsley theatre, which had been thoroughly enjoyed. From discussion with residents and staff there was lots of evidence heard that there are regular activities and also other ad hoc arrangements to involve residents in sing a longs and quizzes. Residents said that they had regular visits from family members or that they could speak to them on the telephone. The deputy manager said that one resident finds it difficult to communicate verbally. She said that staff had made a picture book to help her communicate more effectively so that she could make informed choices about aspects of daily living. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 12 All the residents spoken with said that the food was very good and that they were offered plenty to eat. Residents were seen being offered a choice of fresh fruit and a large bowl of fruit is left in the lounge for residents to help themselves from. Residents were seen to be offered a choice of hot or cold drinks on a regular basis. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Satisfactory arrangements are in place for dealing with complaints. Staff would benefit from updated training on adult abuse to further ensure the wellbeing and protection of residents. EVIDENCE: The deputy manager said that the home has not received a complaint since the last inspection visit. A recommendation was made on the last inspection report that staff would benefit from refresher training on adult abuse. This was found to be outstanding therefore this recommendation is brought forward as a recommendation in this report. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 & 26 The home is clean, comfortably furnished and homely. The fire retardancy of furniture brought into the home by residents needs to be checked to ensure the wellbeing and safety of residents and staff. EVIDENCE: The handy person was busy redecorating one of the lounges during the inspection. Residents liked the new colour saying it was nice and fresh looking. Other communal areas were visited and found to be comfortably accommodated, clean and homely. Several residents’ rooms were seen. These are particularly homely and most residents were seen to have brought their own personal possessions from home. It was recommended in the last report that some furniture in residents’ bedrooms should be checked for fire retardancy. The deputy manager was uncertain as to the status of this recommendation therefore the recommendation stands for this report. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 15 Residents who smoke said that they could use the conservatory or summerhouse. Despite the winter conditions, the gardens were well presented. The bathroom was found to have been redecorated following a recommendation made in the last report. A recommendation in the last report to check the flat roof for leaks had been carried out. The maintenance officer was going through the process of replacing some ceiling tiles which had been previously damaged. The home’s insurance schedule was seen to be in date. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Staffing levels are satisfactory. Staff recruitment practices need to be strengthened. Although there are some good arrangements for staff training, this would be further enhanced by ensuring that moving and handling training is updated. The home has achieved the national minimum standard for the number of staff to be NVQ trained. EVIDENCE: The deputy manager said that they were managing with current staffing levels but were still finding it difficult to recruit new staff. From discussion, most problems are due to the position of the home as it is in a rural area. It is difficult for staff without transport to get there from more urbanised areas. Staff at the home have generally worked there for some time and they said that they loved their job and were well managed. An examination of the most recently appointed member of staff showed a gap in her employment history on her application form. But there was no evidence as to how this had been addressed. The other records required by regulation were available in the file. Two other staff files were found to contain most of the records required through regulation but another application form had been poorly completed. The deputy manager said that training had been booked to update staff on first aid and basic food hygiene and that moving and handling training would also be arranged as records showed that this was needed as it was recorded on file as needing updating in 2005. The deputy manager said that two cleaners are Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 17 currently undertaking NVQ Level 2 training in Housekeeping and that over 50 of the staff team have now achieved NVQ Level 2 in Care. She herself is undertaking NVQ Level 3. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 18 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): 31, 33, 36 & 38 The home is well managed. Residents are consulted about how life in the home may affect them. Generally, health and safety arrangements are satisfactory although staff would benefit from receiving two fire lectures in any twelvemonth period to further ensure the safety of residents in the home. . EVIDENCE: The deputy manager said that the manager is nearing completion of her NVQ Level 4 training and the Commission is aware that she is going through the Registered Managers Award training. The deputy manager was reminded that copies of the Regulation 26 visit need to be forwarded to the Commission. She said that the registered provider was in regular contact and had been across only the day before to check the home. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 19 The minutes of residents’ meetings showed that these take place three monthly and that there is good attendance from residents and that the agenda includes discussion about issues important to residents such as food and activities. The minutes from staff meetings demonstrates regular dialogue takes place about training, health and safety and residents. The records of supervision showed that staff are supervised regularly. However, the records show that supervision had taken place but did not show the topics discussed or if any objectives had been set to be carried out by either party following the supervision. The benefit of recording such was discussed. Records showed that water temperature are taken monthly. The records showed that water temperatures are supplied at a safe temperature. The maintenance certificates for the fire extinguishers, portable appliances were seen to be in date. The fire alarm and emergency lighting certificates were not seen. The maintenance officer said that these had been tested only three weeks before but was uncertain since the manager was not available where the certificates were. He said that the water chlorination had not been checked recently and that he would chase this up. The records of fire alarm and emergency lighting testing were seen to be satisfactory. Staff records showed that they had taken part in regular fire drills. The deputy manager said that two lots of fire training had taken place but unfortunately the training record could not be found for evidencing the training. Those individual staff files examined did not evidence that they had received two fire lectures in any twelve-month period. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 20 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 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 2 3 3 X X 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X X 2 X 2 Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19(2) Schedule 2 26(2) Requirement Staff records must include all the information required by regulation including a full employment history. Arrangements must be made to forward copies of the monthly report to the Commission. Timescale for action 31/03/06 2 OP31 31/03/06 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 Refer to Standard OP7 Good Practice Recommendations Care plans and risk assessments need to be developed further to clearly identify needs and any risk so that staff have a clear understanding how to respond appropriately to meet identified need. Staff would benefit from refresher training on adult abuse and protection. Older furniture needs to be checked for fire retardancy. Staff should receive two fire lectures in every twelvemonth period. Staff would benefit from updated moving and handling DS0000006241.V282982.R01.S.doc Version 5.1 Page 22 2 3 OP18 OP24OP38 4 OP30 Woodlands 5 OP36 training. Staff supervision records should show that there has been an agenda for discussion including any recorded outcomes including objectives to be achieved by both parties. Woodlands DS0000006241.V282982.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 DS0000006241.V282982.R01.S.doc Version 5.1 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!