Inspection on 12/06/07 for Woodlands Gate

This inspection was carried out on 12th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Gate 10/06/08

Woodlands Gate 19/01/06

Woodlands Gate 22/10/05

Woodlands Gate 14/03/05

Woodlands Gate 13/09/04

Woodlands Gate 31/03/04

Woodlands Gate 02/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Woodlands Gate 12 Dingle Road Stourbridge Dudley West Midlands DY9 0RS Lead Inspector Ms Linda Elsaleh Unannounced Inspection 12th June 2007 10:30 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 Gate DS0000024974.V339522.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 Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Gate Address 12 Dingle Road Stourbridge Dudley West Midlands DY9 0RS 01562 885546 01562 885546 admin@sclcare.co.uk www.sclcare.co.uk S.C.L. Care Limited 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) Mrs Patricia Jewess Care Home 21 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (13), Physical disability over 65 of places years of age (6) Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Woodlands Gate is a large converted domestic property located in a quiet residential area of Pedmore near to the town of Stourbridge with good public transport links. There is car parking to the front of the property. The garden to the rear is large and well established with a variety of shrubs, trees and plants. There is a patio area adjacent with a number of tables and chairs. The home is registered to care for 21 older persons and has 17 single bedrooms and two double rooms. Resident’s accommodation is on two floors accessed by a passenger lift. Bedrooms are all decorated individually and reflect resident’s different tastes and personality. Residents may bring some of their own furniture if they wish, after discussion with the manager. The home has a number of bathrooms with assisted bathing facilities located on the ground and first floors. There is a large lounge with a conservatory, a dining room and ‘quiet’ lounge/dining room all situated on the ground floor. Communal areas are decorated and furnished to a good standard. The home offers a range of stimulating social activities for residents. The current weekly charge for this service ranges from £353.00 to £465.00. Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 12th June 2007. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Older People and report on the progress made to address the two requirements from the previous inspection. The inspector’s findings are based on the information received by the Commission for Social Care Inspection, examination of relevant records and documents kept at the home, discussions with the manager, staff and service users, responses received from relatives and other professionals and a tour of the premises. The atmosphere within the home was relaxed and friendly and service users expressed satisfaction with the care being provided. What the service does well: What has improved since the last inspection? Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 6 The refurbishment of the kitchen has been completed and a number of rooms re-carpeted and re-decorated. A lock has been fitted to the cupboard where cleaning materials are kept. The policy and procedures for the safe handling of medication have been reviewed. 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 Gate DS0000024974.V339522.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 Gate DS0000024974.V339522.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): 1, 3 & 6 Quality in this outcome area is good. The home provides good information to prospective service users to enable them to make an informed choice about where to live. Assessments are carried out on their individual needs to ensure these can be met by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective service users are provided with detailed information about the home in the form of a brochure and recently reviewed Statement of Purpose. A copy of the inspection report from the regulating body, Commission for Social Care Inspection (CSCI), is also made available on request by the home. Each service user is issued with a Service User Guide. Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 9 The random selection of service users’ files contained assessments of their needs from the referring authority, healthcare professionals and the home. One relative commented on how the “friendly and easy manner of staff” helped her/his parent to settle into the home. The home does not offer intermediate care. Woodlands Gate DS0000024974.V339522.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): 7, 8, 9 & 10 Quality in this outcome area is excellent. Individual care plans are produced and service users are assured all their health and personal care needs will be fully met. The home has suitable medication policy and procedures to ensure the well being of service users are protected. Service users are treated with respect and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff are familiar with service users individual needs and preferences. Examination of a random selection of files show care plans and risk assessments continue to be produced for each service user. Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 11 A record is kept of all health care appointments and regular consultations take place with health care specialists. The inspector observed good practice in the delivery of care. An internal monthly review is carried out on care plans and risk assessments. This enables changes in care needs to be addressed promptly and risk assessments to be amended or produced. Service users are included in this process wherever possible. The home’s policy and procedures for the safe handling of medication was reviewed in February 2007. There are suitable facilities for the safe storage of medication. The medication record sheets examined were completed to a satisfactory standard and the relevant staff confirmed they are provided with suitable training. There are systems in place to support service users who are able to manage their own medication and/or ointments and creams. Service users’ who spoke with the inspector commented positively about the care being provided. They confirmed personal care is provided in a sensitive manner and in accordance with their individual wishes. Rotas indicate staffing levels are appropriate to meet the current service users needs. The overall responses received from relatives and healthcare professionals were positive about the service the home provides. They confirmed that the managers are available during visits to discuss any concerns and commented that the general atmosphere within the home was welcoming and friendly. Woodlands Gate DS0000024974.V339522.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): 12, 13, 14 & 15 Quality in this outcome area is good. The home supports service users to continue with their chosen lifestyle, where possible. Relatives and friends are welcome visitors to the home. Menus offer both choice and variety. The meals are well presented and served in a pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides an activities programme, based on the interests and requests made during the service users’ meetings. This is displayed on the notice board. Arrangements are made for external facilitators to provide activities such as “movement to music”. The manager stated this was often well attended, whilst interest in other activities fluctuate. Staff reported some service users prefer to follow their own activities, such as visiting local clubs. Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 13 Opportunities are provided for less mobile service users to be escorted on short walks. Records are kept on all activities to monitor popularity and programmes are revised to meet service users interests. A television is provided in the main lounge. The inspector was informed this room is included in the home’s refurbishment programme for this year. The home operates an ‘open door’ policy for visitors between 9am and 9pm. Visitors are requested to contact the home if they wish to visit at other times. The inspector observed a number of visitors arriving at various times throughout the day and the atmosphere was relaxed and friendly. Service users and relatives confirmed they are able to meet in private, often in the service user’s own room. Bedrooms are personalised and some contain small items of furniture the service user has brought with them. The home has two dining rooms. The inspector was invited to join some service users for their mid-day meal in the smaller room. The menu of the day was displayed, offering service users a choice of main meal and dessert. Alternatives are provided on request wherever possible. The table was attractively set and condiments and drinks provided. The presentation of meals and service was excellent. All service users expressed satisfaction with the meals. Staff are aware of each service users likes and dislikes. The manager reported that there were no special dietary needs at present. Woodlands Gate DS0000024974.V339522.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): 16, 17 & 18 Quality in this outcome area is good. Service users are confident their complaints and concerns are listened to and acted upon appropriately by the home. The home has suitable procedures in place to protect service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has policies and procedures for managing complaints and protection of vulnerable adults. The home has not received any complaints about the service or any concerns in respect of the protection of service users. Arrangements are made for all staff to receive training in the protection of vulnerable adults. The manager stated service user’s are consulted about the day-to-day running of the home on an individual basis and at the Residents’ Meetings. Minutes of meetings were seen during this inspection. The home also continues to seek the views of relatives and healthcare professionals and reports good relationships are maintained with both. Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 15 General comments received from service users, relatives and visiting professionals all confirmed they are confident in raising any issues they may have with staff at the home and that these would be satisfactorily addressed. Woodlands Gate DS0000024974.V339522.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): 19, 21, 22, 23, 24, 25 & 30 Quality in this outcome area is good. Service users live in a safe, comfortable and well-maintained home that meets all their individual needs and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained and decorated in a style that gives it a homely atmosphere. The home has a rolling programme for redecoration and refurbishment home. Since the last inspection the refurbishment of the kitchen has been completed and some rooms have been redecorated and recarpeted. Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 17 Bedrooms are suitably furnished and, as previously stated, reflect the service users’ personal tastes. Some service users have chosen to bring some small items of their own furniture. There are toilets and bathing facilities on both floors. A toilet and bathroom on the ground floor is in need of redecoration. The inspector was informed this would be included in the planned redecoration programme. The inspector was informed service users prefer to use the ground floor shower or bathroom, as both are suitably equipped. A bath seat should be fitted in the first floor bathroom to make this facility accessible to service users. There is a suitable equipped laundry area and good arrangements are made for infection control. Cleaning materials are stored in a locked cupboard and information is available on the Control of Substances Hazardous to Health (COSHH). Woodlands Gate DS0000024974.V339522.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): 27, 28, 29 & 30 Quality in this outcome area is good. Service users are protected by the home’s recruitment policies and practices. The home provides competent and trained staff in sufficient numbers to meet the needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The random selection of staff files examined contained all relevant information, demonstrating the home’s robust policy and procedure for recruitment of staff is followed. Newly appointed staff received a planned induction. The home does not employ agency staff or uses the services of volunteers. Staff training is well organised with a planned programme for training and a matrix that enables renewal dates to be easily identified. Staff stated arrangements are being made for them to receive training in caring for people with dementia. Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 19 83 of care staff have completed the National Vocational Qualification (NVQ) Level 2. The deputy manager completed the Registered Manager’s Award (RMA) earlier this year. The rotas indicate the home is adequately staffed during the day and night. Service users reported staff are always willing to assist them. Relatives expressed an overall satisfaction with the care provided. Woodlands Gate DS0000024974.V339522.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): 31, 33, 35, 37 & 38 Quality in this outcome area is good. Service users live in a home that is run in their best interests and has procedures in place to ensure their financial interests are safeguarded. Improvements to the details provided about bed rails in use will ensure the physical safety of these service users is more fully protected. This judgement has been made using available evidence including a visit to this service. Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager has the knowledge and experience appropriate to her role. She has been in post for many years and holds the National Vocational Qualification (NVQ) Level 4 in Care as well as the Registered Manager’s Award (RMA). The home continues to implement a quality assurance system, which includes seeking the views of service users, relatives, stakeholders and staff on a regular basis throughout the year. The results are published in an annual report and this is made available to all interested parties. The small amount of money managed by the home on behalf of service users is securely stored. Appropriate records are kept in line with the home’s policy and procedures. Information kept on service users and additional records are securely stored and confidentiality is maintained. The home has a policy on service users rights to access their personal records and information is available about how to access independent advocates. Appropriate safety checks and routine servicing is carried out on appliances and equipment, with the exception of bed rails. The information provided to staff states “regular checks to be made and any concerns reported”. More detailed information needs to be provided. Manual handling and basic food hygiene training has been provided to staff during the early part of this year. Woodlands Gate DS0000024974.V339522.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 2 Woodlands Gate DS0000024974.V339522.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. 1. Standard OP38 Regulation 23 Requirement More detailed information needs to be provided about the bed rails in use and safety checks carried out to ensure the well being of these service users is fully protected. Timescale for action 07/08/07 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 OP21 Good Practice Recommendations A suitable bath seat needs to be fitted in the first floor bathroom to enable service users on this floor to access this facility. Woodlands Gate DS0000024974.V339522.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West Midlands Regional Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 Gate DS0000024974.V339522.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. 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