Inspection on 19/01/06 for Woodlands Gate

This inspection was carried out on 19th January 2006.

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 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 Gate 10/06/08

Woodlands Gate 12/06/07

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 ORS Lead Inspector Mrs Mandy Beck Announced Inspection 19th January 2006 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 Gate DS0000024974.V268640.R01.S.doc Version 5.1 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.V268640.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodlands Gate Address 12 Dingle Road Stourbridge Dudley West Midlands DY9 ORS 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.V268640.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd October 2005 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. Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which took place between the hours of 09.30 and 14.30. The judgments made during this inspection are based upon information received from the pre inspection questionnaire and 12 comment cards from both residents and relatives. A tour of the premises was also undertaken, staff files were examined and three residents files were selected for case tracking purposes. Time was also spent sitting with the residents and talking to them about life at the home and taking part in the mornings planned activity. What the service does well: What has improved since the last inspection? During the last inspection there were few requirements made, it was pleasing to see that all of the requirements had either been met in full or would be met in the very near future. The manager has improved their record keeping system so that it is now much easier to read residents files, understand their needs and identify when appointments are due for each resident. A nutritional screening tool has also been introduced for all residents giving them further protection against malnutrition Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 6 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 Gate DS0000024974.V268640.R01.S.doc Version 5.1 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.V268640.R01.S.doc Version 5.1 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): None of these standards were assessed at this inspection EVIDENCE: Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 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): 7,8,10 All of the residents have an individual plan of care and can be assured that all of their health needs are fully met. Residents are treated with respect and dignity at all times. EVIDENCE: Residents care plans were seen and included risk assessments for falls, pressure sore risk development, nutritional screening and moving and handling. Those residents who need to use a wheelchair to aid their mobility also had risk assessments in place. Those residents who require bed rails at night to help keep them safe in bed also had appropriate risk assessments in place, plastic rail covers are also provided to reduce the risk of injury whilst bed rails are in use. The care plans for each resident reflect a true picture of their needs and are reviewed regularly, where possible the home tries to include the residents in this process. There was evidence that residents have access to specialist medical, nursing, dental and optical services should they require them. District nurses provide Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 10 support and equipment for residents whose skin is fragile and may require pressure relieving equipment. The administration of medicines was not assessed at this inspection but a medication round was witnessed in order to be assured that previous requirements had been met. Staff were seen to be signing for medicines at the point of administration and observing all residents taking their medication safely. Throughout the inspection it was observed that staff spoke to residents in friendly manner and it was felt that they were all treated with respect. Residents commented that “the girls are lovely they help with anything, I’m not embarrassed”,” they help me get to the toilet”. Staff comments included “I like to talk to the residents they have so much to tell us, they are really interesting”. Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 11 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): 14 Residents are encouraged to exercise choice and control over their lives EVIDENCE: All of the residents are encouraged to make choices about their lives and are actively involved in all aspects of their care. Residents are encouraged to go to bed and to get up when they are ready to do so, they can also choose where they eat their meals. One resident was happy for her meals to be bought to her room. All of the resident’s bedrooms were personalised with possessions from their homes and gave the rooms an individual feeling. All possessions that are bought into the home are recorded and agreed with the management prior to admission. None of the current residents managed their own finances. Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 12 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): None of the above standards were assessed at this inspection EVIDENCE: Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 13 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): 19,26 The home is clean and tidy and residents can be assured that they live in a well maintained environment. EVIDENCE: The home is maintained to a high standard and is decorated in a style that gives it a very relaxed homely atmosphere. Plans for the kitchen refurbishment are taking a step nearer completion, all of the units and appliances have been purchased, a date for installation has yet to be agreed. The repairs to the broken toilet seat had been addressed, in addition to this the home has now purchased protective covers for the bed rails to enhance the safety of service users. The laundry area was also inspected and noted that the COSHH materials were being stored in an unlocked cupboard, this was bought to the attention of the manager at the time of inspection and she will take active steps to rectify this situation. Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 14 Whilst touring the home it was also noted that a resident had a bottle of dettol in their room, the manager stated this is because the resident likes to clean her own products and has always done this. The manager has been asked to produce a risk assessment for this situation and to look at storage to ensure that no other residents would be at risk. Some of the carpets in residents bedrooms had been cleaned recently but they were still stained, these carpets should be replaced as part of the home refurbishment and redecoration programme. Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 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): 27,28,29,30 Residents can be assured that staff are recruited in a safe manner and that they have the knowledge and skills to ensure that residents feel in safe hands all of the time. There are adequate numbers of staff on duty to meet residents needs. EVIDENCE: The home has robust policy and procedures in place for the recruitment and selection of staff. Staff files were examined and were seen to contain all required information including CRB disclosure. The home does not have volunteer workers. Staff training is well organised and the staff matrix easily identifies when staff are due for updates. Mandatory training is offered on an annual basis and all staff are encouraged to attend. More than 50 of the care staff have completed their NVQ level 2, five of the staff have now completed their NVQ level 3 with another member of staff due to qualify soon. A further three staff have also completed their D32 and D33 enabling them to assess other carers undertaking NVQ training. The registered manager has also recently completed the Registered Managers Award. The home does not employ agency staff because it is felt they do not know the residents and would cause too much disruption to the residents. Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 16 All of the staff are registered on TOPSS training for their induction and foundation programmes, this induction is tailored to meet individual need to avoid repetition of NVQ module work. At the time of the inspection the home appeared to be staffed adequately, generally there are 4 care staff on a morning shift, and three care staff for the afternoon, two waking night staff. Residents generally felt that there were enough staff to help with their needs but some comments included “sometimes there doesn’t seem to be enough staff on duty to help people get to the toilet”, “I know they are busy and having to wait for the toilet is part of being in a home”, “they are very busy and sometimes over worked but they always find the time for that little extra and because of this the resident are able to maintain their dignity and individuality”. Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 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): 33,35 Residents are assured that the home is run in their best interests and that their financial interests are safeguarded. EVIDENCE: The quality assurance process that the home has in place is to be commended. The home has an active annual development plan based upon a cycle of planning – action – review,. The annual review includes the views from residents, relatives, staff and stakeholders in the community. Feedback is actively sought and the results are published and made public for all interested parties to read. The registered manager ensures that residents monies are stored safely and the home has policies in place to safeguard residents interests. Written records of all transactions are maintained and receipts are kept. Monies are not pooled Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 18 and are kept separate in secure facilities. The home generally manages only small amounts of money for service users to ensure that they can pay for their newspapers and hairdressing services. Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 2 x X 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 X X 4 X 3 X X X Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 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 OP19 Regulation 16(1) Requirement Timescale for action 28/02/06 2 OP26 23(l) CSCI must be notified in writing of the date that the refurbishment of the kitchen will commence and that this will include repair/replacement of the extractor system (previous timescale of 30/11/05 not met) 01/04/06 A lock must be supplied to COSHH cupboard in laundry, COSHH information on products must be kept in the laundry A hand washing sign must be acquired for the sink in the laundry Risk assessment must be completed for the resident who keeps dettol in their room and suitable storage supplied. The toilet frame in toilet 2 must to be repaired Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 21 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 OP8 Good Practice Recommendations The registered manager should consider alternate methods of observing residents weights if they are no longer able to use conventional scales. The registered manager should consider seeking the advice of the dietician re food supplements for those residents who are frail in order to supplement their diets. Raw meat products should be stored below fresh fruit/veg/salad items (not assessed at this inspection) 2 3 OP8 OP19 Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlands Gate DS0000024974.V268640.R01.S.doc Version 5.1 Page 23 - 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!