CARE HOMES FOR OLDER PEOPLE
Woodlands Care Home Station Road Sandleheath Fordingbridge Hampshire SP6 1PA Lead Inspector
Mr Roy Bega Unannounced Inspection 22nd November 2005 09:30 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.V266773.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. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Woodlands Care Home Address Station Road Sandleheath Fordingbridge Hampshire SP6 1PA 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 22 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.V266773.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. A maximum of three service users in the category PD(E) may be accommodated at any one time Service users in the category PD(E) may only be accommodated on the ground floor 28th June 2005 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 House provides accommodation for 30 older persons in 24 single bedrooms and 3 double bedrooms. The house sits in spacious grounds, which are in the process of being re landscaped. Residents have varying needs with aspects of daily living. Mr P Reynolds is the named responsible individual. Mrs A Wait is the registered manager responsible for the daily running of the home. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report summarises the assessment of the extent to which the National Minimum Standards for Care Homes for older people were being met at the time of the inspection. Standards not inspected on this occasion will be assessed during future visits. This inspection took place over one day, a total of four hours between 9-30 a.m. and 1-30 p.m. Opportunity was taken to look around the home, view records and talk with, residents an staff. It was not possible to obtain the views of relatives due to none being present during the visit. The Commission for Social Care Inspectorate (C.S.C.I.) has agreed a four-year improvement plan for the period May 2004 to April 2008 with regards to the interior and exterior of the home. Subsequent to the previous inspection much work has been completed as detailed in the main body of this report. As acknowledged by Mr Reynolds the refurbishment programme will remain a requirement until all agreed work has been completed. The requirement raised resulting from the previous inspection with regards to social activities was assessed to have been met. As result of this inspection three requirements were raised. What the service does well: The Commission for Social Care Inspectorate (C.S.C.I.) has agreed a four-year improvement plan for the period May 2004 to April 2008 with regards to the interior and exterior of the home. Subsequent to the previous inspection much work has been completed as detailed in the main body of this report. The home is well managed. The staff team are highly motivated and have good relationships with residents. Staff were observed to respect residents and explain aspects of care before carrying it out. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 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 Care Home DS0000011612.V266773.R01.S.doc Version 5.0 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.V266773.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Residents are provided with a clear statement of purpose and a written contract/statement of terms and conditions that outlines services provided. EVIDENCE: The home’s current statement of purpose was seen. It is written in plain English and contains the required information as detailed within the National Minimum Standards. A sample of two residents statement of terms and conditions for living in the home were seen. They contained the required information as detailed within the National Minimum Standards. Mrs Wait informed the inspector that the statement of terms and conditions for residents funded by local authorities is in the process of being amended. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11. Residents are assured that at the time of their death they and their family will be treated with care, sensitivity and respect. EVIDENCE: The home has an appropriate policy and procedure to assure residents at the time of their death, that they and their family will be treated with care, sensitivity and respect. Training in managing death and bereavement has not been provided for staff. Staff spoken with however portrayed a sense of sensitivity when approached with regards to this matter. Residents’ cultural/requirements/ wishes upon death are not recorded in care plans. Mrs Wait informed the inspector that current practice is dependent on family members informing the home that they will take responsibility but agreed to make appropriate records. Cards from relatives expressing their thanks and gratitude with regards to the homes management of recent bereavements were seen. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. The home provides social, cultural, recreational and occupational activities suited to older persons. EVIDENCE: This standard was raised as a requirement resulting from the previous inspection to further develop the cultural, recreational and occupational activities. Discussions and observations indicated that this has been actioned. Staff informed the inspector of the introduction of various age appropriate activities and ability to have time to sit and chat with residents on a one to one basis. (This was observed during the visit.) It was noted that a seasonal theatre trip has been arranged. Residents informed the inspector that they do a lot of different things. There was an open, relaxed friendly, inclusive atmosphere with residents interacting with each other and with staff. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 11 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): 17. Management ensures resident’s legal rights are protected. EVIDENCE: Information and discussions indicated that resident’s legal rights are protected. They are enabled to exercise their rights to participate in the civic process if they wish. At the time of this visit discussions and records seen indicated that all of the current residents have relatives or representatives to act on their behalf. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25 and 26. The home is accessible, safe, clean and well maintained. It meets residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: It was noted that two further bedrooms have been refurbished with a new vanity units and furniture as part of the home’s improvement programme. A sample of three bedrooms were inspected. They are individually and naturally ventilated with windows conforming to recognised standards. Residents have the ability to control the temperature of the central heating both in their bedrooms and communal areas. Radiators and pipe work are guarded to prevent possible burns from hot surface temperatures. None of the bedrooms have en-suite toilet/bathing facilities. There are however, sufficient communal bathroom and toilet facilities to meet resident’s needs. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 13 At the time of the visit the premises were clean, hygienic and free from offensive odours throughout. Systems are in place to control the spread of infection. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored or prepared. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 14 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): 30. Management are working towards ensuring staff receive appropriate training. EVIDENCE: At the time of this visit evidence was seen that staff were attending the following courses – • • Two seniors: Administration of Medication. Five care staff: A day release (for twelve weeks) Infection Control Course. The inspector was informed that the planned training as discussed during the previous inspection of 28 June 2005 which included - Dementia care; Managing Aggression; Adult Protection, Risk Assessments and an updated Moving and Handling has not taken place. The home’s management are also aware that the current ratio of members of care staff who are trained NVQ level 2 in care or equivalent does not meet the 50 requirement. Discussions did reassure the inspector that the home is working towards the required target. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 15 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): 35, 36, 37 and 38. Procedures are in place to safeguard residents financial interests. Staff are not being appropriately supervised. Residents’ rights and best interest are safe guarded by the home’s record keeping and policies and procedures. The safety and welfare of residents and staff are generally promoted. EVIDENCE: The inspector was informed that residents’ families or representatives manage their personal finances. This was reflected in discussions with residents. When residents require money for any purpose, for example the hairdresser, families are invoiced. Mrs Wait agreed it would be best practice that when an invoice/receipt is produced for the resident (if possible), a member of staff sign it as a precaution. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 16 Mrs Wait informed the inspector that staff one to one supervision has not taken place in the period of three months prior to this inspection. This was reflected in discussions with staff. Mrs Wait acknowledged that the requirement is that staff receive formal supervision at least six times a year. The possibility of dividing this responsibility with a deputy or senior member of staff was discussed. No unsafe practices were observed during the inspection. Staff wore protective clothing where required. Certificates were available for required checks of systems and equipment. Hampshire Fire and Rescue Service (HFRS) visited Woodlands on 19 October 2005 to complete a fire safety inspection. A total of ten requirements were made as a result. The Commission for Social Care Inspection received a copy of the report on 7 November and contacted the home. HFRS plan to revisit the home on 1 February 2006 when the requirements are due to be completed. The inspector was informed by Mr Reynolds that most of the work has been completed. Records seen for the purpose of this inspection were up to date and kept secure. Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 17 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 3 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 3 X 3 X X X 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 2 3 2 Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 18 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. 1. Standard OP30 Regulation 18 (1a) & 19 (5b) 18 (2) Requirement The home’s staff training programme for 2006 is to be provided to the commission by the stipulated timescale. Staff are to receive informal supervision at least six times a year. To re commence by the stipulated timescale. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. The work required in HFRS report dated 3 Nov 2005 is to be completed by the stipulated timescale Timescale for action 30/01/06 2. OP36 01/01/06 3 OP38 23 (4 a-e) 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlands Care Home DS0000011612.V266773.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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