Inspection on 25/08/06 for Woodlands HFE

This inspection was carried out on 25th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 HFE 24/02/09

Woodlands HFE 30/01/06

Woodlands HFE 18/07/05

Woodlands HFE 16/11/04

Woodlands HFE 06/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodlands HFE Warwick Avenue Clayton le Moors Accrington Lancashire BB5 5RW Lead Inspector Mrs Christine Mulcahy Key Unannounced Inspection 09:45 25th August 2006 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 HFE DS0000036436.V302686.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 HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands HFE Address Warwick Avenue Clayton le Moors Accrington Lancashire BB5 5RW 01254 232099 01254 396400 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) Lancashire County Care Services Mrs Gail Heaney Care Home 44 Category(ies) of Dementia (13), Dementia - over 65 years of age registration, with number (13), Old age, not falling within any other of places category (31) Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should, employ a suitably qualified manager who is registered with the Commission for Social Care Inspection The home is registered for a maximum of 44 service users to include: Up to 31 service users requiring personal care in the category of OP (over 65 years of age not falling into any other category) Up to 13 service users requiring personal care in the category of DE (Dementia, under 65 years of age) Up to 13 service users requiring personal care in the category of DE (E) (Dementia, over 65 years of age) 30th January 2006 Date of last inspection Brief Description of the Service: Woodlands HFE is registered with the Commission for Social Care Inspection to provide personal care and accommodation for up to 44 older people. Within the overall total there are 31 service users aged 65 years or over and 13 service users aged 65 years or over with dementia. All require personal care. The building is single storey in its own grounds and is located just off the main Whalley Road of Clayton-Le-Moors in Accrington. Whalley Road is situated on a main bus route that offers transport to towns in the Hyndburn area. There is also a well-attended day service sited in the building. The building refurbishment is now complete and provides accommodation with modern furnishings within 3 separate units for the service users. A number of bedrooms are en suite. There are also a number of assisted bathrooms, shower rooms and toilets for the service users throughout the home. Service users receive a copy of the homes service user guide and have access to the Statement of Purpose. Fees range from 320 - £360.50 per week and service users are billed separately for hairdressing, newspapers, magazines and some activities. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection was unannounced and took place over two days on Monday 21st and Friday 25th August 2006. Information was obtained from care plans, staff records, management systems, observations and policies and procedures. There has been one concern made to the CSCI since the last inspection and this has since been resolved satisfactorily. The inspector also spoke to 3 service users, 1 relative, 4 staff, the registered manager and the area manager. What the service does well: What has improved since the last inspection? What they could do better: So that staff can fully meet the service user needs care plans must be drawn up after consulting service users and their relatives. Risk assessments should be included in all care plans to highlight where risk is greater and where choice restrictions are in place. Limited variety of leisure and recreational activities meant that service users social interests and social needs were not being met fully. Further appropriate activities should be introduced to suit service user preferences and capabilities. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 6 Currently a lot of staff time is spent administering medication. Only senior staff have been trained in the safe handling of medication. The number of staff to receive this training should increase to reflect the number of service users in the home and free up senior staff to continue managing the home. 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 HFE DS0000036436.V302686.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 HFE DS0000036436.V302686.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 1,3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the home was not fully up to date therefore prospective and new service users were not able to make an informed choice about where to live. Service users had initial care manager assessments prior to admission to the home. EVIDENCE: There is a service information document that is used for all Lancashire County Care Services residential homes. Fully updated information about the home since the refurbishment was not available. The current available information needs to include the address of the Commission for Social Care Inspection. Service users case tracked had been admitted following a full care management assessment and some care plans had based on the assessment. The home does not provide intermediate care. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 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): OP 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistent and incomplete care plans meant that personal and health care needs could not be met properly. Medication was well managed and service users were protected by the homes medicine policies and procedures. Care practiced observed showed service users privacy and dignity was respected. EVIDENCE: The care plans examined using the case tracking process were inconsistent and incomplete. Case tracking confirmed that some care plans did not have the relevant information for staff to meet the service user needs. On two of the care plans examined there were no photographs to confirm the service user identity. Service user diary sheet had been written up regularly but contained one- liners like, “slept well”, “fine, no problems”. Risk assessment tick lists were available for service users but did not identify how the risks would be managed. This meant that staff were unable to provide adequate care and protection because there wasn’t enough information. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 10 One service user review record had been left blank. This meant there was no up to date information about the service users progress and plans for their future at the home. An incident report written by the registered manager on 16.2.06 identified a service users aggressive behaviour towards staff and other service users. However there was no follow up information recorded and no risk management strategies in place to reduce the risk of future episodes. This meant that staff were not able to identify future risks and hazards that might put other service users and staff at risk of harm. There was no written risk management strategy for a service user who had choice restrictions in place. All risks should be discussed prior to admission according to health and social services protocols and in discussion with the service user. This should then be agreed and recorded in the individual plan of care and reviewed. The registered manager said that the home was in the process of reviewing the current service user plans of care and would soon be introducing a revised version that would be used throughout the organisation. There was a care plan for one service user who was prone to pressure sores and was receiving treatment from the District Nurse and a pressure relieving mattress was seen being used by the service user. Access to other health professionals was given and evidence of district nurse, chiropody and ophthalmic services were seen. Observations made and discussions with a relative and service users confirmed that staff treated service users with dignity and respect. Staff were seen helping service users and talking to them in a kind and sensitive manner. One relative said, “I talk to all staff, they’re all very good”. When asked if his relative was wearing her own clothing he said, “Yes she’s wearing her own clothes and always looks clean and tidy”. Medication was stored and recorded properly. Only staff trained in the safe handling of medicines administered medication. The registered manager was advised to ensure that the training is made available to the wider staff team. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 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): OP 12, 13, 14, & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The lack of varied leisure and recreational activities meant that service users social interests and needs were not being fully met. Visiting from relatives and friends is flexible. Service user autonomy and choice was not fully maximised in relation to meals therefore variety and nutrition could not be ensured. EVIDENCE: The registered manager said that wherever possible service users were able to make choices about aspects of their lives including waking and going to bed times and handling their own finances. Case tracking, examination of records and discussion with service users confirmed that many service users were responsible for their own finances. Other service users finances were handled by their relatives. Service users religious and cultural needs were identified when they moved into the home as part of the admission process. The registered manager said t there was regular contact with the hairdresser, the church and the local library and books were changed at the home every three months. In addition to this the home provided activities such as bingo, regular daily newspapers, televisions in a number of communal areas and light physical activity in the Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 12 form of biff ball. The recent good weather had encouraged a lot of outdoor activity and service users had enjoyed this. One said, “It’s been lovely, now that we’ve got the new garden, I’ve been sitting out there with my family. The registered manager said that some service users liked to go out with relatives, however this depended on the activity. The homes activities record was examined and while it was acknowledged these activities took place the registered manager was reminded that service users should be given a varied choice of activities to ensure they meet their individual and social needs. Visitors were observed at the home at various times of the day. Menus were changed regularly and service users were reminded of the day’s menu each morning. Menus were kept in the kitchen area and service users when asked didn’t know what was for lunch that day. Service users said they were asked each morning what they wanted for lunch and if they didn’t like it they would always get something else. However the inspector observed one member of staff leaving the kitchen with two sachets of cuppa soup for a service user as an alternative meal because he didn’t like the meal on offer. The registered manager said that the new domestic hours would enable the cook to look at the menus and introduce appropriate alternatives and would enquire about the cuppa soup offered to the service user. Hot and cold drinks were available throughout the day and discussion with the cook confirmed that special theraputic diets were provided when necessary. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 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): OP 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints made by service users and relatives were acted on and recorded. A majority of the staff team have received training in protection of vulnerable adults. EVIDENCE: The homes complaints procedure specifies how complaints may be made and who will deal with them. There is an assurance that complaints will be responded to within a maximum of 28 days. Although there have been no complaints to the CSCI since the last inspection the registered manager said that complaints made would include details of the investigation and any action taken. There were procedures for staff to follow if they suspected an incident of abuse had taken place. 35 staff had received vulnerable adults training. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 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): OP 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All areas of the home were safe and well maintained. The home was clean, pleasant and hygienic. EVIDENCE: A tour of the building showed that the home provided accommodation for service users meeting their individual and collective needs. The recent building refurbishment ensured service users lived in a safe well-maintained environment. There were ample accessible toilets for service users close to lounge and dining areas. Assisted baths were available in each area of the home. Where rooms weren’t en suite toilets were within close proximity of service users bedrooms. En suite facilities accommodated service users own wheelchairs and other aids. Call systems with an accessible alarm facility were provided in every room. Grab rails were provided in bathrooms, toilets and corridors. Aids, hoists and Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 15 assisted toilets and baths were installed and capable of meeting the assessed service user needs. Doors to service user bedrooms were fitted with locks and service users were provided with a key as requested. Bedrooms seen had been furnished by the home with good quality furniture. Some bedrooms had been personalised by service users who had brought their own furniture and possessions with them. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 16 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): OP 27, 28, 29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment process ensured the protection of service users. Staff had received appropriate training to carry out duties expected of them. EVIDENCE: The duty rota was examined and showed which staff were on duty and at what times. Care staff were on duty in sufficient numbers. The file of one employee was examined and showed that the registered manager had followed the homes recruitment procedures. All pre employment checks had been carried out. A record of training and development by all staff was examined and showed that staff had the skills, knowledge and competency to do their work. 70 of the care staff was qualified to NVQ Level 2 and above. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 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): OP 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interest of the service users The health, safety and welfare of service users aand staff were promoted and protected. EVIDENCE: The manager of the home has many years experience of working with older people and is able to meet the needs of the service users through her knowledge and skills. She is currently undertaking training to obtain a Post Grad Certificate in dementia care A tour of the building highlighted that first aid boxes must be easily accessed by staff. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 18 Fridge and freezer temperature records were examined and were accurate. All food stored was labelled and in date. An internal audit is done annually to determine service user satisfaction. There were details of fees charged and paid. A record of service user cash held at the home was kept. A record of water temperatures was kept along with other relevant health and safety records. Fire extinguishers and other fire equipment complied with the local fire service. An internal audit is done annually to determine service user satisfaction. There were details of fees charged and paid and a record of service user cash held at the home was kept. Cash held corresponded with the amounts recorded on service user account sheet. The registered manager was reminded to ensure that where possible service users must sign to agree relatives manage personal finances. A record of water temperatures was kept along with other relevant health and safety records. All care staff were issued with pocket size antibacterial hand wash to prevent cross infection. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 2 X X 2 Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 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 OP1 Regulation Schedule 1 Reg 5(1) Requirement The registered manager must ensure that up to date information about the home must be made available to perspective and new service users in the form of a Service User Guide and Statement of Purpose. Please forward a copy of each document to the CSCI by the date shown. The registered manager must ensure that all service users and their representatives are consulted with in order to prepare a written plan of care that meets the service user health, social and welfare needs. The plan must be reviewed at least monthly and include a risk assessment to highlight where risks are greater and where choice restrictions are in place. Service users are given more opportunities for stimulation through leisure and recreational activities in and out of the home that suits their needs preferences and capacities. DS0000036436.V302686.R01.S.doc Timescale for action 03/11/06 2. OP7 15(1) 13(4)(c) 03/11/06 3 OP12 16(2)(n) 03/11/06 Woodlands HFE Version 5.2 Page 21 4 OP15 16(2)(i) 5 OP35 12(2) 6 OP38 13(4) Please forward a copy of the homes activity programme to the CSCI by the date shown The registered manager must 03/11/06 ensure that each service user is offered three full meals each day one of which must be cooked. Please forward a copy of the revised menu including alternatives to the CSCI by the date shown. The registered manager must 03/11/06 ensure that relatives sign to agree that designated staff are able to cash service user pensions. There must be appropriate records confirming this decision. The registered person must 03/11/06 ensure that the first aid box is accessible to care staff at all times. 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 OP30 Good Practice Recommendations To complement the good practice in place and to reflect the number and needs of the service users more care staff should receive training in the safe handling of medication. Woodlands HFE DS0000036436.V302686.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 HFE DS0000036436.V302686.R01.S.doc Version 5.2 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!