Inspection on 09/08/05 for Woodlands

This inspection was carried out on 9th August 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 21/10/08

Woodlands 09/11/06

Woodlands 24/01/06

Woodlands 03/03/05

Woodlands 11/11/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Woodlands 69 Queens Road Oldham OL8 2BA Lead Inspector Sandra Bennett Unannounced 9 August 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 F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodlands Address 69 Queens Road, Oldham, OL8 2BA 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) 0161 624 9344 0161 624 9344 Woodlands Residential Care Home Limited Mrs Caroline Jane Howard CRH Care Home 18 Category(ies) of DE Dementia - 1 registration, with number DE(E) Dementia over 65 - 10 of places MD Mental Disorder - 1 MD(E) Mental Disorder over 65 - 8 OP Old Age - 14 SI(E) Sensory Impairment over 65 - 1 Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home is registered for a maximum of 18 service users to include: * up to 14 service users in the category of OP (Old age not falling within any other category). *up to 10 service users in the category of DE(E) (Dementia over 65 years of age). *up to 1 service user in the category of DE (Dementia under 65 years of age). *up to 1 service user in the category of SI(E) (Sensory Impairment over 65 years of age). *up to 8 service users in the category of MD(E) (Mental disorder excluding learning disability or ementia over 65 years of age). *up to 1 service user in the category of MD (Mental disorder excluding l learning disability or dementia under 65 years of age). One named service user under 55 years of age in the category DE can be admitted into the home. 2 3 The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 3rd March 2005 Brief Description of the Service: Woodlands is a detatched Victorian property situated one mile from Oldham town centre, close to local amanities and public transport. Accommodation is proivided in 16 single rooms, 15 of which have ensuite. Of these, two bedrooms share an adjoining ensuite. One of the bedrooms is below the minimum 10 square metres required by the National Minimum Standards. Communal areas consist of two lounges and a dining room which leads onto a small conservatory area providing addittional seating and a quite area for residents. There are garden and patios areas to the front of the property which are accessible to residents through the provision of ramps and handrails. There is a car park to the rear of the home. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unscheduled inspection took place on the 9th August 2005. During the inspection four residents were interviewed in private, as were three members of staff and two relatives. Ten residents questionnaires were left for completion, none had been returned at the time of writing this report. A selection of residents and staff records were scrutinised as well as other documentation including staff rotas and medication records. Communal areas of the environment were inspected and a selection of residents rooms. What the service does well: Woodlands is a well managed home. Staff receive training and supervision leaving them confident in their role. Care for each resident is planned based on the needs identified on their assessment. Residents commented on their involvement in this process saying “staff always bring my file to meetings “. Staff was observed to treat residents with patience and courtesy and had an in depth knowledge of residents likes and dislikes. Other comments made by residents included “ its like living in an hotel here”, “ I have never been happier than I am now” and “ staff are very kind there is always some one there to help you”. Relatives commented that they are encouraged to visit and dine with the resident if they wish and are always made to feel welcome. They also felt that they were kept informed of their relative’s progress. One resident commented that “ the food is very good and if you don’t like it they will make you something else staff ask us what we want.” The small home environment promotes inclusion of residents. Staff dine with service users to provide a family atmosphere. Activities are discussed at residents meetings. At the time of the inspection a future holiday at Pontins was being planned. Photographs of residents involved in community trips or activities were displayed in the home. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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 F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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 F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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) 1,2,3,4 and 5. Information is available and visits are encouraged to enable residents and their families to make an informed choice about the home. Assessments of residents needs are obtained prior to their admission. Terms and conditions reflect the rights and responsibilities of both parties. EVIDENCE: One resident had been had only been in the home for a few weeks. Time was spent in discussion with the resident and their family. Comments made by the resident were that “ I liked the home as soon as I visited and met the other residents and staff”. Relatives confirmed they had been given information on the service the home provides prior to admission and that a number of homes had been looked at before making a decision on which one was most suitable to meet the residents needs. Examination of resident’s files found that a detailed assessment of need was obtained prior to their admission. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 9 Contracts of residents reflected the rights and responsibilities of both parties. Intermediate care is not provided at Woodlands. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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) 7,8,9 and 10. Resident’s health care needs were met. Shortfalls in the evaluation of resident’s care plans; nutritional screening and risk assessments have the potential to place them at risk. Residents are treated with respect and dignity by the staff. Resident’s right to privacy is upheld. Procedures for the storage, recording and handling of medication needed to be reviewed. EVIDENCE: Through interviews with relatives, residents and staff it was identified that the needs of residents were being met. One relative confirmed they had been given a copy of the residents care plan on admission and had recently been involved in a review with the resident and health professionals. Another residents stated, “ Staff always bring my file with them at meetings.” Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 11 Examination of records relating to residents care needs although comprehensively put together, found these did not always match the outcomes for residents in the home, for instance social care plans did not reflect activities residents were involved with. There were inconsistencies in recording dates and signing of care plans and risk assessments and the completion of nutritional screening. A positive aspect was the ‘getting to know you form’, which is completed by residents or their families giving a detailed picture of the resident’s preferences. In one instance a review had taken place, which required a detailed care plan this had not been completed. In order to maintain the good standard in the home more effort is needed in maintaining care plans to ensure risk to residents do not occur. Professional visit were recorded on resident’s files. Examination of medication record and administration found errors in dispensing and over stocking of medication. Some medication had been overstocked and should be returned to the chemist. One service user was self-medicating an aspect of their medication. An audit trail must be maintained to assess and monitor the dosage. All senior staff had received training in the administration of medication. At interview staff demonstrated a good knowledge of their residents needs likes and dislikes. They gave examples of how the privacy and dignity of the residents is maintained through confidentially and their involvement in daily life. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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) 12,13,14 and 15. The daily routine within the home was flexible, and enabled residents to make choices in various aspects of their daily life within the home. Residents enjoyed the food provided by the home. Activities provided residents with enjoyment and stimulation. The recording of these on individual social care plans would enhance this process. Residents were able to maintain contact with relatives and friends. EVIDENCE: On the day of this inspection the residents were having a barbecue in the garden and patio areas of the home. The barbecue consisted of burgers, chicken, salad, quiche and a glass of wine. The inspector was invited to dine with residents enabling a discussion to take place on daily life in the home. Comments made by residents included “ its just like being in a hotel here” “if we didn’t like this meal we could have something else you know”, “there are always fresh flowers on the dining tables.” “staff ask us every day what we want for lunch.” Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 13 Relatives were also asked to join in the barbecue and reported they were always made to feel welcome. Residents confirmed that residents meetings took place on the 3/7/05 and gave examples of issues that had been discussed recently which were a holiday planned for next year to Pontins. One resident said they went out every day if only to the local park. Pictures were displayed on the wall of recent trips to Chatsworth House and pub lunches. Three residents went out swimming and another out shopping on a regular basis. Within the home the mixed client group of mental health and older people provided additional stimulation and interaction between residents. Good interaction between residents and staff was also noted. A diary of activities is maintained on a communal level. Residents would benefit if their interest were recorded more in depth on care plans. This would compliment the ‘getting to know you’ form the home completes which covers, likes and dislikes, favourite music, hobbies and their preferences in tea, coffee. One resident said, “I have never been happier as I am now, staff are very kind and there is always some one their to help you. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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 and18 The complaints procedure ensured that all interested parties were aware of how to complain and the process that would be undertaken. Limited staff training in the protection of vulnerable adults may pose a risk to residents. EVIDENCE: The home had a written complaints procedure. All residents spoken to expressed confidence that complaints would be appropriately dealt with. Staff also felt confident that any concerns they had could be discussed with the manager and they would be listened to. There was a written procedure for dealing with allegations of abuse. Interviews with staff and the manger found that training in adult protection had not been undertaken formally with some staff having undertaken this through NVQ training or in house provided by the manger. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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) 19,20,21,24 and 26 Since the last inspection the home has continued with improvements in the environment and garden areas. There are sufficient communal facilities to meet resident’s needs. Resident’s rooms were personalised, safe, clean, well maintained and free from odour. EVIDENCE: The home was well maintained, safe, clean, tidy and free from odours. Since the last inspection the home has continued with their refurbishment programme and improvements to the environment. There are two lounges and a dining room, which leads to a small conservatory. One room is allocated a smoking area. A selection of resident’s rooms was inspected and was found to be personalised and homely. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 16 In addition to the ensuite facilities there are sufficient toilet and bathing facilities, situated close to communal areas. A new kitchen was being installed at the time of inspection. Discussions with residents highlighted their favourite bit of the refurbishment plan, that being the landscaped garden and patio areas which now has a fish pond and built in barbecue. One part of the garden is slopes down however handrails and ramps are provide for easy access. A patio area at the top of the garden is available for residents who cannot physically manage to get to the bottom of the garden. However this does not mean that residents in this area are left out of activities, the garden is designed to allow all service users to be included. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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) 27,28,29 and 30 Staff recruitment was robust and provided protection for residents. A high level of staff training is provided which would be complimented by formal training in the protection of vulnerable adults to ensure residents are not put at risk. Staffing levels in the home were sufficient to meet the needs of residents. EVIDENCE: Two newly recruited staff files were examined and found to have the appropriate references and criminal records bureau checks. Over 50 of staff are trained to NVQ level 2. Each member of staff has a training file. Training provided for staff include, dementia care, moving and handling, care and responsibility and de-escalation techniques. Staff interviewed were confident in their role. The manager is a qualified RMN and dementia care nurse who has provided training in the protection of vulnerable adult, which is also included in NVQ training. Training in the protection of vulnerable adults needs to be a formal process by a recognised body. Staffing levels in the home were sufficient to meet the needs and numbers of residents at the time of inspection. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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 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) 31,32,33,34,35,36,37 and 38. The leadership and management style of the home is inclusive of residents and relatives views. Appropriate accounting and financial procedures for the home and residents were in place. Health and safety is promoted in the home. Staff receive regular supervision. More rigor is needed in some aspects of the homes recording systems. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 19 EVIDENCE: The manger is a qualified RMN RGN and dementia care nurse who has recently completed NVQ 4 in care and the registered managers award. Residents, relatives and staff are consulted on developments in the home through residents and staff meeting. Residents gave examples of discussions and information sharing of a proposed extension to the home. A selection of records relating to money held by the home on behalf of residents was examined. These were appropriately maintained with receipts for expenditure retained on file. The registered person reported that the financial procedures relating to the home were appropriate and that the business was financially viable. Through examination of staff records and interviews with staff evidence was gained that regular supervision of staff had taken place. Issues identified earlier in this report relate to closer monitoring of the homes recording systems i.e. care planning and the administration and recording of medication. Documentary evidence was seen of maintenance contracts and servicing reports for the lift, the fire detection and alarm equipment and hoist. Staff had received training in health and safety, moving and handling and safety awareness. Formal training in the protection of vulnerable adults would enhance this. Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 N/A 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 3 3 3 2 2 Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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 7/12/37 Regulation 15(1) Requirement The registered person must ensure care plans of residents are signed and dated by the person completing them and the service user or their representatives. Social aspects of residents care should also be included. The registered person must ensure that the nutritional screening of residents takes place on admission. The registered person must ensure that medication prescribed to residents is administered accordingly. Any medication no longer required must be returned to the chemist. An audit trail must be maintained for service users who self medicate. The registerd person must ensure that staff receive formal traing in the protection of vulnerable adults. Timescale for action 31/10/05 2. 8/37 12 Immediate 3. 9/37 13(2) Immediate 4. 18/30/38 12(1) 30/12/05 Woodlands F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 22 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 F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton-under-Lyne OL7 OQD 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 F54 F04 s5547 Woodlands un v242396 090805 Stage 4.doc Version 1.40 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!