Inspection on 16/04/07 for Woodlands Care Home

This inspection was carried out on 16th April 2007.

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 Care Home 26/07/06

Woodlands Care Home 22/11/05

Woodlands Care Home 28/06/05

Woodlands Care Home 08/09/04

Woodlands Care Home 29/04/04

Woodlands Care Home 04/06/03

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Woodlands Care Home Main Road Sandleheath Fordingbridge Hampshire SP6 1TD Lead Inspector Craig Willis Unannounced Inspection 16th April 2007 09:20 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 Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Care Home Address Main Road Sandleheath Fordingbridge Hampshire SP6 1TD 01425 652710 01425 652950 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) Woodlands House Retirement Limited Mrs Alison Sarah Wait Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (3) Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category PD(E) may only be accommodated on the ground floor 12th December 2006 Date of last inspection Brief Description of the Service: Woodlands Care Home is located in the village of Sandleheath, a rural area of the New Forest approximately one and a half miles from Fordingbridge. Woodlands Care Home provides accommodation for 30 older people in 24 single and 3 double bedrooms. The house has spacious grounds, which are landscaped and accessible for residents. Fees for the home are £400-£450 per week. There are additional charges for hairdressing services, chiropody and cost of transport for hospital appointments. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a review of the information the provider sent to the Commission for Social Care Inspection (CSCI) following the last inspection including a pre-inspection questionnaire and a site visit to the home on 16 April 2007. During the site visit the inspector spoke with residents, care staff, the manager and the provider. A tour of the building was made and the inspector observed the care that staff were providing to residents. CSCI comment cards were received from one resident and two relatives. Documents relating to the running of the home were inspected during the visit. CSCI carried out a pharmacist inspection on 17 August 2006 to follow up on concerns about medication practice raised in the last key inspection. During this visit it was found that improvements were still needed to the medication practices at the home. CSCI carried out a random inspection of Woodlands on 12 December 2006 to follow up on concerns raised in the previous key inspection. During this visit it was found that improvements had been made to the assessment of people before they move into the home, the support available for people to choose meals, staff training and staff supervision. However, improvements were still needed in the medication records, care plans and the checks carried out on staff before they start work in the home. What the service does well: What has improved since the last inspection? People’s needs are set out in care plans. These documents are now being regularly reviewed and updated where necessary. Medication records have been improved and are now fully completed. This helps to protect residents. All staff have received training in types of abuse and how to protect people. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 6 Improvements have been made to the home’s recruitment procedures and all staff are now thoroughly checked before starting work. Staff have received additional training and are now able to complete the National Vocational Qualification in care. The manager now regularly meets with staff individually to provide supervision. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems to assess the needs of people before they move into the home, which assures residents that their needs can be met. EVIDENCE: The Commission carried out a random inspection of Woodlands Care Home on 12 December 2006. The inspector found that the requirement made at the last key inspection that people must not move into the home until a full assessment of their needs had been carried out had been met. During this visit the records of five residents were inspected. Needs assessments were available for all five residents and had been completed prior to them moving into the home. Copies of care management assessments were also available. The assessments include physical needs, social and cultural needs, personal care, daily living skills, health, social behaviour, mental state Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 9 and any medication they are prescribed. The resident who completed a CSCI comment card said they received sufficient information to decide whether the home would meet their needs. The home does not provide intermediate care and therefore standard six is not applicable. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The details recorded in care plans, support to access health services and take medication and the way staff support residents ensures that they are treated with dignity and respect and their needs are met. EVIDENCE: The Commission carried out a random inspection of Woodlands Care Home on 12 December 2006. The inspector found that the requirement from the last key inspection that care plans need to be reviewed monthly and reflect the changing needs of residents was partially met and the requirement that a signed record of the date on which medication was administered must be maintained had not been met. During this visit the records of five residents were inspected. Each resident had a care plan that had been developed from their needs assessment and set Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 11 out how those assessed needs should be met. Plans were reviewed each month and where people’s needs had changed the care plan had been amended to reflect this. Risk assessments were completed for identified hazards and included action that should be taken to minimise the risk of harm. Nutritional assessments are completed and residents are regularly weighed. One resident spoken with said they were aware of their care plan and happy with the contents. Residents’ records showed that they were supported to attend a range of health services, including GP, optician, district nurse, community psychiatric nurse and chiropodist. Residents spoken with said they were able to see their doctor when they needed to. The resident who completed a CSCI comment card said they always receive the medical support they need. The home uses a monitored dosage system, with the majority of medication supplied by the pharmacist in blister packs. Medication was securely stored in a locked trolley and administration records had been fully completed. Records were available of medication that had been returned to the pharmacist to be destroyed. All staff responsible for administering medication have received training. The manager reported that following the last inspection she has been regularly checking the medication records to ensure the correct procedures are being followed. There is a policy and procedure for the administration and control of medication. This document sets out procedures staff must follow for the ordering, receipt, storage, administration and disposal of medication. The Commission carried out a pharmacist inspection on 17 August 2006 and made recommendations that Temazepam be stored as a controlled drug and that the home had a controlled drug register for the recording of any controlled drugs, including Temazepam. The manager reported that following consultation with their supplying pharmacist, Temazepam tablets were not being stored as a controlled drug, as they have been supplied in the blister packs with the other tablets. The Temazepam was being recorded in the medication administration records with the other medication and records inspected had been fully completed. The manager reported that she had obtained a controlled drug register and this would be used if any residents were prescribed other controlled drugs. Residents spoken with said that staff treat them well and provide support in a manner that maintains their dignity. During the visit staff were observed interacting with residents in a friendly and professional manner. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good support to residents to take part in social activities and visitors are made to feel welcome. A choice of good food is provided for residents and meal times are a relaxed, social occasion. EVIDENCE: The Commission carried out a random inspection of Woodlands Care Home on 12 December 2006. The inspector found that the requirement from the last key inspection that a menu must be supplied to enable residents to make a choice of meals had been met. During this visit, residents spoken with said that they enjoyed the activities provided in the home. Activities that are organised include a visiting singer, bingo and arts and crafts. There is also a selection of games and books available and residents spoken with said they enjoyed going out in the garden when the weather was nice. The home maintains links with local churches and a service is held each month. The resident who completed a CSCI Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 13 comment card said there were usually activities arranged that they could take part in. The home has an open visiting policy and records showed that there were regular visitors. One relative who completed a CSCI comment card said staff are “always very welcoming and helpful”. During the visit a mealtime was observed. Staff were observed providing appropriate support to residents that needed it, spending time with them to help them eat in a relaxed manner. Residents spoken with said that the food was good and they could have something different if they wanted it. There is a planned menu that provides a varied and balanced diet and a choice of meals. Residents are supported to make a choice from the menu each morning. The resident who completed a CSCI comment card said the “meals are exceptionally good”. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems to investigate complaints and protect residents from abuse. This gives residents confidence that their concerns will be taken seriously and acted upon. EVIDENCE: The Commission carried out a random inspection of Woodlands Care Home on 12 December 2006. The inspector found that the requirement from the last key inspection that staff must receive training to prevent residents being placed at risk of abuse was met. The home’s complaints procedure is supplied to residents and their relatives with the service users’ guide and is displayed in the home. Residents spoken with said that they were aware of the home’s complaints procedure and were confident that any complaints would be taken seriously and responded to appropriately. Both relatives who completed a CSCI comment card said they were aware of home’s complaints procedure and the staff have always responded appropriately to any concerns that have been raised. No complaints have been received by the home or CSCI since the last inspection. Staff have received training in adult protection issues and those spoken with demonstrated a good understanding of issues of abuse and action they should Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 15 take if they witness or suspect abuse. There are adult protection and whistle blowing procedures available in the home. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained and generally clean and efforts are being made to resolve the odour in one area of the home. There are good infection control procedures in place, which helps to keep residents safe. EVIDENCE: The Commission carried out a random inspection of Woodlands Care Home on 12 December 2006. Following this visit requirements were made that the home must be kept free of offensive odours and practices in relation to the management of soiled laundry must be improved to prevent the risk of cross infection. This was made in response to a very strong smell of urine in one of the bedrooms and soiled clothing being soaked in the laundry room sinks, which were blocked. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 17 During the visit this bedroom was inspected twice. On the first visit there was a strong smell of urine in the room. By the second visit, later in the morning the room had been cleaned and was much fresher, although there was still a residual odour. The manager reported that the carpet in this room is professionally cleaned every month and cleaned daily with a wet carpet cleaner. The cleaner reported that she ensures she cleans the room in the morning as soon as possible after the resident has got up and will clean it again during the day if necessary. The manager also reported that advice has been sought from the resident’s GP and community psychiatric nurse. The provider reported that the carpet is specifically designed to prevent urine soaking through to the floorboards. The provider also said he is replacing the kick boards at the base of the sink as he thinks some urine has soaked into them. All other areas of the home were clean and smelt fresh and residents spoken with said this was always the case. The resident who completed a CSCI comment card said the home was always fresh and clean. The home has six bathrooms, although only one of them has an assisted bath that can be used by the current residents. The provider reported that he had applied for a grant to convert one bathroom into an accessible shower, to enable residents to choose between a bath and a shower. The provider said he would complete this work whether or not he received the grant. Residents spoken with said that the lack of accessible bathrooms was not a significant problem for them and they were able to have a bath when they wanted. The home has a laundry in the basement and soiled items are not taken through food preparation or storage areas. Soiled items are now placed in specialist bags, which are then placed directly into the washing machines. Staff have access to protective clothing, such as gloves and aprons and were observed using them during the visit. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures, staff training and the deployment of staff in sufficient numbers help to ensure that residents are protected and their needs are met. EVIDENCE: The Commission carried out a random inspection of Woodlands Care Home on 12 December 2006. The inspector found that the requirement from the last key inspection that 50 of staff must be qualified to NVQ at level 2 or above had been met. The requirement that staff must not be employed at the home until the provider has obtained satisfactory Criminal Records Bureau (CRB) checks had not been met. An additional requirement was made at the random inspection that staff must receive manual handling and first aid training. The home has a staffing rota, which demonstrates that there are three or four care staff available in the morning, three staff in the afternoon / evening and two staff overnight. In addition to the care staff there is a member of cleaning staff on duty each day. Residents spoken with said they felt there were sufficient staff to meet their needs. Staff spoken with also said they felt there were sufficient staff on each shift to complete the work required. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 19 The manager reported that seven of the nine care staff are currently working towards the NVQ level 2. The two other staff are new and currently working through an induction to the service. The recruitment records of four members of staff were inspected during the visit. These were found to contain all of the required checks, including a Criminal Records Bureau disclosure and two written references. The manager reported in a pre-inspection questionnaire that these checks are in place for all staff working at the home. Since the random inspection all staff have received training in moving and handling and all staff are booked to attend first aid training before the end of April 2007. Staff undertake an induction when they start work and other courses, including fire safety, food hygiene, adult protection, dementia care, infection control and medication. Further training sessions are booked throughout the year to ensure all staff receive the training they need. Both relatives who completed a CSCI comment card stated that care staff have the right skills and experience to look after people properly. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and has good systems to keep residents and staff safe and monitor the performance of the home. EVIDENCE: The Commission carried out a random inspection of Woodlands Care Home on 12 December 2006. The inspector found that the requirement from the last key inspection that staff must receive formal supervision at least six times a year had not been met. During this visit the manager reported that she has a City and Guilds social service qualification and has just enrolled on the registered manager’s award. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 21 The home has a quality assurance system, which includes gaining the views of residents and their relatives through questionnaires. The results of these questionnaires were seen during the visit and contained positive feedback about people’s experiences in the home. The manager reported that any areas of dissatisfaction that are identified from the feedback are rectified. The provider said he comes into the home every day to assess how the home is running. There is a programme in place for the refurbishment of the building, which the provider reported he expected to take a further eighteen months. The manager reported that the home does not hold money for any residents. The manager reported that she has met with staff for formal supervision meetings and plans to do so every two months. Staff spoken with confirmed that they had formal supervision meetings and had found them useful. Records demonstrated that regular checks were being undertaken of the home’s fire alarm system and fire equipment, the gas equipment, lift and water systems. Chemicals were kept in locked cupboards when not in use and assessments had been completed for chemicals used in the home. Staff have received health and safety training. A record is kept of accidents that occur in the home. Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 2 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 3 X 3 X 3 3 X 3 Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlands Care Home DS0000011612.V333040.R01.S.doc Version 5.2 Page 25 - 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!