Inspection on 30/01/06 for Woodlands HFE

This inspection was carried out on 30th January 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 25/08/06

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 Unannounced Inspection 30th January 2006 10:00 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.V273093.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 HFE DS0000036436.V273093.R01.S.doc Version 5.0 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.V273093.R01.S.doc Version 5.0 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 reqiring 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) 18th July 2005 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 home is located on the main New Line Road close to local shops, a library and other amenities in the town centre of Bacup. The home is situated on a main bus route that offers transport to all towns in the Rosendale 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. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second in the inspection year and took place over one day. The service was inspected against the National Minimum Standards for Older People. Case tracking of service users also took place along with the rooms they occupy in the home. Observations were made of the care provided and the service users were invited to have a discussion with the inspector to discuss their experiences of life in the home. The inspection spoke to 4 service users, 3 care staff, 1 relative and the registered manager. Breaches in regulations and standards that pose an immediate risk to service users have been highlighted for urgent action. What the service does well: What has improved since the last inspection? A tour of the building confirmed the home had undergone an extensive refurbishment and building programme. All furniture including beds and bedroom furniture was new. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 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 HFE DS0000036436.V273093.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 HFE DS0000036436.V273093.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): OP1 Service users had the information they needed about the home before moving in. EVIDENCE: The homes Statement of Purpose had been updated to include information about the amount and type of furniture service users could bring with them when moving into the home Woodlands HFE DS0000036436.V273093.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): OP 7, 9, 10 Information on one service user plan of care was not up to date and did not fully set out their social care needs. The control of medication was well managed promoting good health Staff did not always use the term of address preferred by the service user. EVIDENCE: Case tracking of a service user who moved into The Woodlands in September 2005 confirmed that care plans had been drawn up from the initial service user assessment. A majority of the service user plan of care had not been fully competed and daily record sheets had not been completed on a daily basis. Information required to fully meet the service user needs was not available and hadn’t been sought since the service user admission 5 months earlier. The service user had not been allocated a key-worker and the plan of care required a full review. A requirement was made for the registered manager to ensure that the service user plan of care sets out in detail the action to be taken to ensure that all aspects of care needs are met and the plan is reviewed by care staff in the home at least once a month. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 Page 10 There was a medication policy and procedure at the home. Written guidance was available for staff to follow when administering medication. Policies and procedures examined ensured service user safety. All medicines were stored securely ensuring service users were kept safe from harm. Medication Record Sheets were completed accurately. There was a separate medicine trolley for each living unit and the inspector observed the registered manager administering medication following the homes policies and procedures. The inspector discreetly witnessed a member of the care staff team affectionately using an inappropriate name to describe a service user. The service user was present but was unable respond in his defence due to his lack of capacity. A requirement was made for the registered manager to ensure that proper provision for the service user health and welfare is made by taking into account the service user wishes and feelings. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 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 Service users were given leisure and recreational opportunities in and outside of the home. EVIDENCE: Case tracking and discussion with service users confirmed they could exercise their choice about food, routines of the day, social activities, and religious observance. The registered manager had introduced an activities record for staff to record all daily activities involving individual service users or groups of service users in each unit. The inspector examined the activity records and noted that service users had taken part in gentle exercise, watching video, sing-a-longs, and helping with small domestic tasks around the home. The records also contained brief details of a variety of entertainers who had visited the home. The registered manager said that she had organised a clothes party for February for service users who were unable to visit the local shops. When asked one service user said, “We generally choose what we want to do, I sometimes get involved but see a lot of my family because they visit regular.” The registered manager went on to explain that a number of service users found comfort in the monthly visits and Communion from the local Baptist Minister. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 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): OP 16, 18 The homes clear and effective complaints procedure included the stages and timescales for the process. Service users knew who to complain to. Procedures to protect service users from abuse were in place. EVIDENCE: There was a simple clear and accessible complaints procedure. A copy of this had been given to all service users at The Woodlands. When asked service users said that they knew whom to complain to. One service user said, “If I had a complaint I would talk to the manager.” When asked the registered manager and staff confirmed they always listened to and acted on the views and concerns of service users and others. The registered manager said that that service users were always listened to and issues were sorted out before they became problems. The inspector examined the homes record of complaints and noted that no complaints had been made since the last inspection. There was a robust procedure for responding to suspicions or evidence of abuse or neglect (including whistle-blowing) that ensured the safety and protection of service users. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 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): OP 19, 22, 24 All areas of the home were safe and well maintained. Specialist equipment, furnishings, toilet and washing facilities met service user needs. EVIDENCE: The location and layout of the home was suitable for it’s stated purpose. It was accessible safe and well maintained meeting service users individual and collective needs. Building and refurbishment work had been completed to a good standard and had been designed to meet relevant guidelines. 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 assisted toilets and baths were installed and capable of meeting the assessed service user needs. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 Page 14 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. One service user said, “ Things here are fine now, I’ve managed to keep some of my own furniture in my bedroom. Just one problem last night with the bedroom door lock but they’re getting it fixed today.” The registered manager confirmed there had been minor problems with some areas of the new refurbishment, but these areas were being reported to and addressed immediately by the building contractors. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This section was not assessed at this inspection EVIDENCE: Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 Page 16 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 33, 38 The homes annual development plan ensures the home is run in the best interest of the service users. The registered manager ensures safe working practices to safeguard the welfare of service users and staff. EVIDENCE: The home is continuously monitored through an annual service user survey. The results of the survey are published and made available with the homes Service User Guide. Feedback is actively sought form service users through a service user questionnaire. Where possible these responses are acted on immediately to ensure the service is run to meet service user needs. Following a requirement from the last inspection a copy of the homes fire evacuation procedure was given to the local fire officer to ensure it met with their requirements. The registered manager stated that the local fire officer was satisfied that the procedure ensured the protection of service users. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 Page 17 The inspector also examined a number of policies and procedures that were posted around the building. These were found to be up to date and ensured compliance withy relevant health and safety legislation. Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 3 X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) 13(4)(c) Requirement The registered manager must ensure that all service users or 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. The registered manager must ensure that proper provision for the service user health and welfare is made by taking into account the service user wishes and feelings. The registered manager must ensure that all staff use the term of address preferred by the service user. Timescale for action 30/01/06 2 OP10 12(3) 30/01/06 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 Good Practice Recommendations Standard Woodlands HFE DS0000036436.V273093.R01.S.doc Version 5.0 Page 20 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.V273093.R01.S.doc Version 5.0 Page 21 - 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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