Inspection on 19/10/05 for Woodlands Care Home

This inspection was carried out on 19th October 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 Care Home 05/07/07

Woodlands Care Home 30/05/06

Woodlands Care Home 18/05/05

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Woodlands Care Home Woodlands Care Home Great North Road Wideopen Newcastle Upon Tyne NE13 6PL Lead Inspector Janine Smith Unannounced Inspection 19th October 2005 9.40 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 DS0000062615.V252611.R01.S.doc Version 5.0 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. DS0000062615.V252611.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlands Care Home Address Woodlands Care Home Great North Road Wideopen Newcastle Upon Tyne NE13 6PL 0191 217 0090 0191 217 0090 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) North East Care Homes Ltd Mrs Linda Elizabeth Gallon Care Home 40 Category(ies) of Dementia - over 65 years of age (29), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (10) DS0000062615.V252611.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Once the resident in the MD(E) category leaves the home, the CSCI must be notified immediately. This place will then revert to category DE(E). 18th May 2005 Date of last inspection Brief Description of the Service: Woodlands was purpose built to provide personal care (but not nursing care) for up to forty elderly people of both sexes. Service users living in the home include people who require care due to old age and physical frailty and people with memory loss including dementia type illnesses. The home is located in a residential area of Wideopen, which has shops and pubs in the locality. There is a bus route passing the home. The building consists of two storeys, which provide level access throughout the building. There is a passenger lift to the first floor. There are 32 single bedrooms and four double rooms. Eight of the single bedrooms are equipped with en-suite facilities. DS0000062615.V252611.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 81/2 hours. No advance notice was given to the home. A partial tour of the premises took place and a sample of the care records were inspected as well as other records. The inspector spoke with the Manager, 5 of the staff on duty and 12 residents staying in the home. There were 36 residents staying in the home on the day of inspection. Since the last inspection, North East Care Homes Ltd., made an application to change the registration categories applying to this home to enable it to provide care for more people with dementia type conditions within the overall number of places. This application was agreed by the Commission. What the service does well: What has improved since the last inspection? The Manager, all of the senior carers and a carer, are undertaking a training course, ‘Positive Dementia Care’, which is provided through Newcastle College. Since the last inspection, good progress has been made in assessing residents to find out their needs re continence and nutrition. Risk assessments are also being carried out to find out if there is a risk of residents having falls, getting DS0000062615.V252611.R01.S.doc Version 5.0 Page 6 pressure sores or infection. The care staff are making much more detailed and informative notes on a daily basis, which helps ensure that residents’ welfare is monitored closely and all of the staff are kept informed. The bathrooms and toilets have been redecorated and the lighting improved. Other areas of the home are also being redecorated. What they could do better: Care planning needs to be more thorough, which helps to ensure that the staff are fully informed about the needs of each resident. The Manager and the staff team were already working together to identify how they could make improvements. Two satisfactory written references must be obtained before anyone starts work in the home. Other vetting checks were being carried out satisfactorily but the Manager was advised to ask candidates to confirm whether they had received any Police Cautions. Induction training is carried out, however, this is not currently covering the full Topss Standards, due to problems finding a training provider. This needs to be put in place to ensure that new staff are fully trained. There are insufficient quality assurance measures. These need to be put in place, and should include obtaining the views of residents and other interested parties at regular intervals. This information then helps the home to check its performance to make sure it is doing a good job. The staff records showed that some staff have not had training in food safety and infection control. This training should be provided for the protection of residents and staff. Essential fire safety checks have not been carried out within the home at regular enough intervals. Documentary evidence of inspection and maintenance of essential equipment in the home must be provided to show that residents and staff are being protected. DS0000062615.V252611.R01.S.doc Version 5.0 Page 7 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. DS0000062615.V252611.R01.S.doc Version 5.0 Page 8 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 DS0000062615.V252611.R01.S.doc Version 5.0 Page 9 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): These standards were inspected at the last inspection. EVIDENCE: DS0000062615.V252611.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 9. There are good arrangements in place to ensure that residents’ care needs are regularly assessed, which helps staff to know what type of support residents need. Improvements in care planning need to continue, to help ensure that the staff team are fully informed and aware of the support they need to provide. There are good arrangements in place to ensure that residents’ health care needs are met. Personal support is offered in such a way as to promote and protect residents’ dignity. Some improvements in the handling of medication are required, to ensure residents are not placed at risk. EVIDENCE: Two care records were looked at. Since the last inspection, good progress has been made in assessing residents to find out their needs re continence and DS0000062615.V252611.R01.S.doc Version 5.0 Page 11 nutrition. Risk assessments are also being carried out to find out if there is a risk of residents having falls, getting pressure sores or infection. The care plans drawn up following this process were found to contain relevant individual plans of care but did not cover all needs. For example, the GP had been contacted about a resident losing weight and a dietician had given advice about his diet, the support he needed to eat his meals and the need to weigh him weekly. Whilst the care staff were aware of these needs, it had not been written up in a plan of care. The record showed he had been weighed weekly to the beginning of September but not since. Those care plans in place were being updated daily with good detail about the welfare of the resident. There was evidence that GPs, Community Nurses and consultants were regularly consulted for advice and treatment and for medication to be reviewed where necessary. There was evidence in the care records that the resident had seen an optician and dentist recently but there was no mention of chiropody being provided. All of those residents spoken to, who could comment, said that they were treated well by the staff. Two said that the food was very good. One resident said, ‘The staff are obliging, its ok here pet’. Another resident said, ‘the staff are wonderful’. The inspector saw that residents were well groomed and attention paid to their dress. The inspector saw staff being caring and giving sensitive support to residents when needed. The system for the storage, ordering and administration of medication was examined and found to be safe, except for the following. One particular medication is supplied in sachet form. Several residents are prescribed this medication and one person’s supply is being used for all of these residents, because of the problem of transporting bulky boxes of the medication. Advice was given to stop this practice. It was apparent from one record, that a resident had only been given a particular medication once a day, instead of twice a day, over a couple of weeks. This mistake had been put right. A handwritten change to the prescribed medication was signed and dated in one case but not another. DS0000062615.V252611.R01.S.doc Version 5.0 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 the following standard(s): Standards 12, 13, 14 and 15 were assessed at the last inspection. EVIDENCE: DS0000062615.V252611.R01.S.doc Version 5.0 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): Standards 16 and 18 were assessed at the last inspection. EVIDENCE: The Manager stated that no complaints have been received since the last inspection. DS0000062615.V252611.R01.S.doc Version 5.0 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): These standards were not assessed. The shared areas of the home were toured and found to be clean with no unpleasant smells. The lighting in bathrooms has been improved. EVIDENCE: DS0000062615.V252611.R01.S.doc Version 5.0 Page 15 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 and 30. The induction training for care staff does not meet Topss standands. These standards need to be met so that new staff are given the information they need on how to provide appropriate and good care. Additional training in providing care for people with dementia, has been put in place for some of the senior and long serving staff, which helps to ensure that staff have the in-depth knowledge and skills necessary to provide good care. Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. EVIDENCE: Discussion with the Manager and with members of the staff team provided evidence that the numbers of care staff on duty, excluding the Manager, are as follows:8 am to 8 pm 8 pm to 8 am 5 care staff 3 waking night care staff An Activity Organiser also works with residents in the home to provide stimulating activities over 5 days a week. A further Activities Organiser is to begin work in the home shortly. Given that the home are now in the process DS0000062615.V252611.R01.S.doc Version 5.0 Page 16 of changing their service to provide care mostly to people with dementia type illnesses, the care staffing levels provided need to be reviewed to ensure that enough staff are on duty at all times to meet residents’ needs. Housekeepers, cooks, kitchen assistants, and maintenance and administrative staff are also employed in the home. The staff were observed to work hard and be attentive and respectful to residents throughout the inspection. The records of two recently recruited members of staff were examined. Vetting procedures were found to be thorough, apart from only one reference was obtained in one case. Candidates for posts are asked to complete a statutory declaration of offences. This currently does not include asking for information on any official police Cautions. The Manager confirmed and records showed that induction training is carried out, however, this is not currently covering the full Topss Standards, due to problems finding a training provider. Currently 4 of the care staff team have achieved NVQ 2, 4 have an NVQ3 and one has an NVQ4, which means 47 of the care staff team have now achieved NVQs. Since the last inspection, the Manager, 7 of the senior staff and a carer have begun a training course, ‘Positive Dementia Care’, which is being run by a local college. One of the carers has also attended a fire safety course run by the Fire Brigade to enable him to carry out the fire safety checks in the home and train other staff. DS0000062615.V252611.R01.S.doc Version 5.0 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 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, 35 and 38. The Manager provides clear leadership, which ensures that the home is well run and the staff team are fully aware of their roles and responsibilities. There are insufficient quality assurance measures in place. These need to be introduced so that the views of residents and other interested parties are obtained at regular intervals, so that the service provided by the home can be regularly assessed to make sure it is doing a good job. Generally, good systems were in place for the handling of residents’ financial interests, which helps to safeguard them. Some health and safety issues were raised, which need addressing to ensure that the home provides a safe environment for residents. EVIDENCE: DS0000062615.V252611.R01.S.doc Version 5.0 Page 18 The Registered Manager, Mrs Linda Gallon, is managing the home well. The positive comments of residents and the staff team give confidence that the Manager provides good leadership throughout the home. A full quality assurance programme has not been set up yet. However, meetings have been held with residents and relatives. The system for handling and storing money held on behalf of residents was looked at. This was found to be appropriate, however, receipts should be obtained where residents pay for hairdressing. An audit check of one resident’s record showed that the balances held matched that recorded in the records. A personal allowances record was looked at and was clearly recorded. The staff team are given training in moving and handling skills and other health and safety training. However, there was a lack of evidence that some staff had received training in food safety and infection control. Fire safety checks have not been carried out at the frequency advised by the Fire Brigade. The staff team have not received fire instruction at regular enough intervals. Maintenance and servicing records were looked at, but up to date evidence could not be found to show that the fire safety systems and some of the other essential equipment in the home are being serviced at regular intervals. DS0000062615.V252611.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X x STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 DS0000062615.V252611.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 Requirement Service user plans must be in sufficient detail to provide clear guidance to staff on the actions to be taken to meet their health and welfare needs. Service users must be involved in drawing up their plan of care and they, or their representative, should be asked to sign their agreement to the plan. Previous timescale of 31/8/05 not met. Medication must only be given from the resident’s own prescribed supply, not anyone else’s. The Medication Administration Records must be checked carefully to ensure that medication is administered correctly. Any medication errors must be notified to the Commission. Dose changes should be signed and dated. Review staffing levels to ensure adequate staffing in place at all times as the resident population changes. DS0000062615.V252611.R01.S.doc Timescale for action 31/03/06 2 OP9 13(2) 30/10/05 3 OP27 18 30/11/05 Version 5.0 Page 21 4 5 6 OP29 OP30 OP33 19 18 24 7 OP38 23(4)(c) 8 9 OP38 OP38 18 13(4) & 23 Two satisfactory written references must be obtained prior to recruiting staff. Induction training to full Topss standards must be provided. Undertake effective quality assurance, including seeking the views of residents and other stakeholders, about the service provided. The fire alarm must be tested weekly. The emergency lights must be checked monthly for faults. Fire drills must be carried out at the frequency advised by the Fire Brigade. The details of such fire safety procedures must be entered in the Fire Log Book. The previous timescale of 30/6/05 has not been met. Staff must be given training in food safety and infection control as necessary. Provide up to date documentary evidence to show that the following are inspected and maintained at adequate intervals: Fire alarms, fire extinguishers, emergency lighting system, hoists, gas boiler and system, electricial wiring system, electrical appliances. 30/11/05 31/03/06 31/03/06 30/11/05 31/03/06 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP29 Good Practice Recommendations Obtain updated British National Formulary. Amend Statutory Declaration of Offences to ask applicants to provide details of any Police Cautions. DS0000062615.V252611.R01.S.doc Version 5.0 Page 22 3 OP35 Obtain receipts where residents pay for hairdressing in the home. DS0000062615.V252611.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000062615.V252611.R01.S.doc Version 5.0 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. 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