Inspection on 07/07/05 for Woodlands

This inspection was carried out on 7th July 2005.

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 23/01/07

Woodlands 24/01/06

Woodlands 13/12/04

Woodlands 01/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Woodlands Grimston Road Kings Lynn Norfolk PE30 3HH Lead Inspector Jenny Rose Announced 7 July 2005 th 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 I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodlands Address Grimston Road, Kings Lynn, Norfolk, PE30 3HH 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) 01553 672076 Norfolk County Council Carole Ann Heley Care Home 40 Category(ies) of Dementia (13), Old age, not falling within any registration, with number other category (27) of places Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home can up to 27 service users who are older people not falling in any other category The home can up to 13 service users who are elderly and have dementia The home is to up to 40 older people That the manager of the home is only responsible for the management of personal care offered to service users accomodated at this establishment That the management of the home ensures there is always a member of staff on shift who has training in the care of people with dementia. This is to be implemented by end March 2004 That Norfolk County Council undertakes a review of the windows with a view to replacement of those which are causing discomfort ot present a risk to the service users. This review to be completed by end March 2004 Date of last inspection 13th December 2004 Brief Description of the Service: The home is a two-storey care home that is owned and managed by Norfolk County Council and is situated in South Wootton on the outskirts of King’s Lynn. It is set beside ‘Crossroads’, a large day centre for older people, which is also owned by Norfolk County Council. The home is within easy reach of King’s Lynn and is on a bus route that serves the South Wootton area from the town centre. Nearby are local shops and other facilities, for example, a post office and public house. The home was first built in 1963 as a residential home for older people. In 1998 an extensive refurbishment programme was completed. As part of this programme a 13-bedded unit for the elderly mentally frail was developed within the home, known as the Heather Unit. There were lounges and reception rooms for service users in the main building offering facility for quiet space or company and activity. There was a large dining room, which served the twenty-seven service users in the main unit. Heather unit had its own dining room and lounge. The home offered both permanent and short-term care as well as two places for day-care. The home has thirty-nine single bedrooms and one double room on the ground and first floors, although these are all used as single rooms. There is a passenger lift. The home has a ramp to the front entrance, which provides good access for wheelchair users. There are large grounds to the front and the rear and there is a secure garden area for service users from Heather Unit Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection taking place over 7 hours on a weekday. The Manager, Mrs Carole Heley was present throughout the inspection. There were 40 service users in the home on the day, 27 in the Main Unit and 13 in the Heather Unit. There was a pre-inspection questionnaire and 43 returned, completed comment cards for the Main Unit and 13 from the Heather Unit. Preparation had taken place in the CSCI office. A tour of the building was undertaken. Records were seen, 5 service users were spoken to in a group, 3 service users privately, 1 visitor and 3 members of staff. What the service does well: What has improved since the last inspection? * * * * * * * * Automatic fire closers have been fitted on doors in the Heather Unit. All windows were now fitted with window restrictors. Redecoration had taken place in bedrooms. A Stannah stair lift had been installed, in addition to passenger lift, giving service users choice. All beds have recently been replaced. The arrangements for the recording, handling, safekeeping and safe administration of medicines has been improved. The numbers of staff completing their NVQ training is now 60 , which is to be commended. The Manager can now relinquish her remaining responsibilities for the neighbouring day centre, with the recent appointment of a Manager there. I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 6 Woodlands 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 I55s34240Woodlandsv230287070705Stage 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 I55s34240Woodlandsv230287070705Stage 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, 5 The procedure for assessing the prospective service user’s needs ensures that he/she and their representatives can be assured that the home will be able to meet their needs. EVIDENCE: There is a comprehensive and detailed assessment of the needs of prospective service users, involving social workers and other healthcare professionals if appropriate. One service user spoken to, who had been in the home for a year, said that prior to her admission, the social worker had arranged respite care for her every six weeks, which meant that when she was permanently admitted she was fully aware that the home would meet her needs and she said that both she and her daughter were very happy with the care she received in the home. Woodlands I55s34240Woodlandsv230287070705Stage 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 10 There are comprehensive and detailed care plans which ensure that staff able to meeting the service users’ personal and healthcare needs. EVIDENCE: There are good, comprehensive care plans, with photographs, which include personal care and health needs, good social histories, and night care plans They also include such details as to whether service users prefer their bedroom doors closed and other personal preferences., including those for food. Where service users wished, the care plans contained details of funeral arrangements. There are monthly reviews and these were seen to be signed by the service user and/or their relative or representative, if appropriate, and the keyworker. There was evidence that other healthcare professionals were involved where necessary, for example the Community, the Community Psychiatric Nurses and services for the visually impaired. Some Staff had received training in sensory impairment. One relative spoken to said that she was “more than happy” with her father’s care and that she could not fault anything in the home. Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 10 The majority of the comment cards reported satisfaction with the care received at the home and there were several very complimentary remarks. A Pharmacy Audit had taken place the day before. The medication is in MDS form and kept in a locked, chained trolley in both units. The Care Co-ordinator explained that a monthly audit is carried out as the new MAR sheets arrive and that there is a good relationship with the Pharmacy. An independent Pharmacist undertakes a Pharmacy Assessment, which was seen, and takes up any queries with the GP. The medication fridge temperatures were checked and in order, together with the contents of the controlled drugs cabinet. No service users were administering their own medication, although there is a policy in place for this. It was evident from speaking with service users and observing staff, that service users are treated with respect and their dignity and privacy upheld. Woodlands I55s34240Woodlandsv230287070705Stage 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) 12, 13, 14, 15 The emphasis on activities within and outside the home, together with the appetising meals give variation and interest in service users’ lives. The fostering of family and community ties for service users’ and the opportunities to exercise choice and control over their lives enhances their quality of life. EVIDENCE: There is high priority given to activities in the home and there are two members of staff whose part time responsibility this is. On the day of the inspection these members of staff were attending a course on Activities. The Activities are also well recorded with those people attending and also a short record of the success, or the difficulties arising during the day, especially outings. There is an activities room with much equipment, such as picnic bags for outings, a darts board, videos, games, books and materials for crafts. There are group outings, which are well advertised in the home and individual outings. A Cream Tea invitation was in the visitors’ book for all visitors. A group of service users spoken to recalled some of the outings, which had taken place this year and were looking forward to the next ones. In the Heather Unit service users’ doors were named and decorated by the service users. Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 12 There are plans to make a Reminiscence Room with appropriate contents. A start has already been made with the purchase of a 1930/40’s radio. Service users are able to maintain contact with family and friends and in the local community as they wish. One service user’s daughter visits twice a week and another relative commented that he and his brother were “more than happy with the care” given to his mother who has been in the home a year. His mother had been well known in the local community and is able to maintain contact through other visitors to the home. One service user was observed to be having her hair done by her own hairdresser she had known for 30 years. The Manager reported that other service users are taken to their own hairdressers on a one-to-one basis, which is to be commended. One service user’s relative said that during her father’s recent illness, she and her family, had been welcomed to visit and help care for her father in aiding his recovery. One service user spoken to has purchased a small electric wheelchair in which she can move independently around the home. Another service user confirmed that he liked to get up late and was eating his breakfast later in the morning. Another partially sighted service user was able to take exercise on his own in a secure garden. Meals are taken in a pleasant dining room and were seen to be appetising, nourishing and attractively presented. There is choice, which was confirmed by one service user, who also commented that the cooking was “good”. A Complaints/Ideas for Menus Box was in the hall for anonymous comments/suggestions. This is seen to be good practice. Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 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 standard(s) 16, 18 A clear complaints procedure and staff training serve to ensure that service users are protected from abuse. EVIDENCE: There is a clear complaints procedure and every service user and their representatives receive a copy of this on admission to the home. All visitors, staff and service users spoken to were clear as to whom they should complain should the need arise. The majority of comment cards also recorded this, although a small minority were unsure of the procedure. The complaints book was seen and complaints were seen to be dealt with appropriately. This included a complaint about molehills in the lawn of the Heather Unit, which had been very persistent, making the mowing of the grass very difficult. All staff spoken to were aware of the issues of the protection of vulnerable adults from abuse and felt able to report any such incidents if necessary. Training in this area is consistently updated. They were also aware of the Whistle Blowing Policy within the Home. Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 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 standard(s) 19, 20, 24, 26 There are a number of sitting areas in the Main Unit which provide comfort and variation for service users, but the sitting area in the Heather Unit is cramped and an extension to this area would provide choice and more comfort for service users and their visitors. EVIDENCE: There had been many improvements since the last inspection. Fire closers on doors in the Heather Unit had been fitted and all window restrictors were now in place for the whole Unit. Repairs and redecoration had taken place and the Property Surveyor for Norfolk County Services was inspecting the premises on the day of the CSCI inspection. All the beds in the home had now been renewed, but the Manager was in the process of risk assessing the brakes on the bed legs, following an accident on the day to a service user’s leg. Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 15 A Stannah stairlift had been installed since the last inspection, which gave service users the choice of that or the passenger lift, and another access to the first floor in times of emergency breakdown. There are several communal areas in the main unit in which service users can sit, one area contains a fish tank, which service users said they enjoyed. The dining room overlooks a most attractive courtyard with hanging baskets and an awning for shade in the hot weather. This is very commendable. There is a large, enclosed garden for the service users in the Heather Unit, including a summer house, which the Manager said was well used in good weather. However, the sitting space for the service users in the Heather Unit is cramped for 13 service users, 3 staff and visitors, especially when activities are taking place for a group. Members of staff reported that service users do not like to use the Dining Room for seeing their visitors as it often adds to their confusion; in addition, it is not always appropriate for service users to see their visitors in their rooms, especially if several visitors came at once, which is often the case in this Unit. There is therefore a Requirement There are several other areas within the Main Unit, including the activities room, a hairdressing room and a training room for staff All the service users’ bedrooms seen were personalised and comfortable. One service user spoken to, whose hobby had been making replica steam engines, had photographs of these in his room and was looking forward to being able to display one of his engines in his room. Several service users had phones in their rooms and one commented: This is “a wonderful place; lovely room, warm, light…good food and wonderful staff”. The home is pleasant and hygienic. Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 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 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, 28, 29, 30 Staff are enthusiastic and competent and good training opportunities ensure that the changing needs of service users are met. EVIDENCE: The home is adequately staffed and the employees are experienced and competent to care for older service users. Service users and staff spoken to said that there were enough staff available, although there were a minority of comment cards which indicated that this was not necessarily everyone’s view. Staff spoken to were enthusiastic and enjoyed their work. They all felt there was a good staff team and that they could approach the Manager and the Care Co-ordinators. They reported that there were staff meetings, sometimes about particular issues, which they found useful and evidence of the Minutes of these was seen. They felt they had good training opportunities, and one staff member felt very supported by the Manager in this. Staff recruitment files contained all the information required and there were Staff Development files for all members of staff. Staff supervision took place regularly and was appropriately recorded. The level of NVQ ll training was 60 . All staff in the Heather Unit have received training in Dementia. One service user remarked of the staff, “everyone is polite and I am treated well”. A group of service users spoken to said “They are lovely girls who work here”. Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 17 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, 32, 33, 38 Good record keeping and a comprehensive quality assurance programme of continuous improvement ensure that the home is run in the best interests of service users. EVIDENCE: The Manager’s responsibilities for the neighbouring day service with 45 places each day had lessened since the last inspection, but the recent appointment of a Manager there meant that these could now be relinquished. Service users, staff and visitors spoken to confirmed that the home was run in an open and inclusive manner. A recent quality assurance survey confirmed that the home is run in the best interests of the service users. The monthly audits seen of such areas as medication, fire tests, supervision and care plans ensure that there is a programme of continuous monitoring and improvement. The most recent service users’ survey which takes place annually was awaiting analysis. Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 18 A number of health and safety records were seen and provided evidence that these issues are appropriately dealt with. Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 19 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 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 x x 3 Woodlands I55s34240Woodlandsv230287070705Stage 4.doc Version 1.30 Page 20 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 OP20 Regulation 23(2)(h) Requirement The Registered Person should ensure that the communal space provided for service users in the Heather Unit be extended to give choice to service users appropriate to their circumstances Timescale for action 31 March 2006 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 OP38 Good Practice Recommendations It is recommended that risk assessments be carried out on the brakes on the bedlegs of the new beds for the safety of service users. 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