Inspection on 14/12/05 for Woodlands House

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 House 18/09/07

Woodlands House 19/09/06

Woodlands House 10/05/05

Woodlands House 12/10/04

Woodlands House 29/06/04

Woodlands House 20/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Woodlands House 118 Cavendish Road London SW19 2HJ Lead Inspector Emma Dove Unannounced Inspection 14th December 2005 10:10 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 House DS0000034082.V274121.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 House DS0000034082.V274121.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodlands House Address 118 Cavendish Road London SW19 2HJ 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) 020 8408 8552 020 8332 1044 Central & Cecil Housing Trust Eileen Nartey Care Home 64 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (28) of places Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Nursing Places To include no more than twenty service users requiring nursing care at any one time. Dementia Care Comprising of three units of twelve service users on each floor. There must be two members of staff on each unit between the hours of 7.30am and 9.30pm. One member of staff must be available to cover night duty for each unit between the hours of 9.00pm and 7.45am. Residential and Nursing Care On the first floor there must be two care staff available on the unit 7.30am to 9.30pm and one care staff to cover night duty between 9.00pm and 7.45am. On the second floor there must be two care staff available on the unit from 7.30am to 9.30pm and one care staff to cover night duty between 9.00pm and 7.45am. In addition a qualified 1st level nurse must be available to cover both nursing units twenty four hours a day. This nurse must not have any management responsibilities for the home other than within the nursing and residential provision where based. Additional Staff An additional member of the care staff team must be available between 9.00pm and 7.45am to offer assistance and cover breaks throughout the home. Management One full time Manager 40 hours per week One Deputy Manager 40 hours per week Senior Staff The registered provider must ensure that a named person designated as the senior person, in charge of the home is available at all times. Ancillary Staff Cook 105 hours per week Kitchen assistants 164.5 hours Housekeeper 35 hours per week Domestic staff 136.5 hours per week between the hours of 9am and 5pm Laundry staff 91 hours per week Administrative staff 37.5 hours per week Reviews The organisation must ensure that the above minimum staffing levels remain under review and that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users. 3. 4. 5. 6. 7. 8. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 5 9. 10. 11. Distribution of Staff The number and distribution of nurses, care staff and ancillary staff must be reviewed at regular intervals. If at any time, the evidence indicates that there are insufficient staff of any category available to meet the assessed needs of service users, the NCSC will require additional staffing as appropriate. Assessment The registered provider must demonstrate that each transferred service user has had an in house needs led assessment since 01.02.02 by 31.11.02, that this is recorded on the individual’s file and that it can be demonstrated that individual needs are being met appropriately. To vary the category to allow the home to admit one named service user under the age of sixty-five years, who has learning disabilities. 10/05/05 Date of last inspection Brief Description of the Service: Woodlands House is a purpose built care home which has the capacity to provide nursing care for twenty older people, residential care for twenty four older people who may have dementia and twenty older people. Within these numbers, eight beds have been designated to provide intermediate care, four beds allocated for nursing interim care and four beds allocated for residential interim care. Sixty-two residents are currently residing at the home. The home is owned and managed by Central and Cecil, a charitable organisation who own and manage two other similar services in the local area. Accommodation is provided over three floors. A lounge, dining room, kitchenette, bathrooms and single bedrooms are available on each floor. Residents have access to enclosed gardens to the rear and side of the home. Each floor of the home is served by a lift. The home is situated in a residential area of Colliers Wood, within a ten to fifteen minute walk of local shops, public transport systems and churches of a number of denominations. The home is staffed twenty-four hours a day by trained nursing staff, care assistants and domestic staff. Three meals are provided daily with drinks and snacks available between mealtimes. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of five hours on the 14th December 2005, by two regulatory inspectors. The inspection consisted of examination of records, inspection of communal areas of the home, talking to residents, visitors, staff and the registered manager. The inspectors had the opportunity to speak with sixteen residents, one visitor and seven members of staff. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be more person centred, to detail residents full needs so that staff can meet individual’s needs. All records must be dated and signed by staff. The medication fridge on the nursing unit must be maintained within the recommended range. A person employed to co-ordinate activities would provide more regular sessions and ensure residents have access to appropriate activities and outings. All staff should complete training in dementia care and staff who are responsible for supervising staff should complete training in supervision. All staff must receive regular supervision. The fire alarm must be tested weekly for safety reasons. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 7 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 House DS0000034082.V274121.R01.S.doc Version 5.1 Page 8 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 House DS0000034082.V274121.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 An appropriate Statement of Purpose and Service Users Guide to the home are in place, giving prospective residents information required to make an informed decision regarding moving into the home. EVIDENCE: The Statement of Purpose and Service Users Guide contain information to enable prospective residents to choose to move into the home. These documents have not changed since the last inspection of the home. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Care plans are in place and have been reviewed as required, however care plans must contain more detail to enable staff to fully meet resident’s needs. Residents are treated with respect and their privacy is maintained. EVIDENCE: Residents files contain assessments, a personal history, social profile and care plans which have been completed by staff, however some files did not contain a completed social profile and staff had not signed and dated some records. The home uses a set format for care plans, which includes sections on breathing, eating, continence, sexuality, communication and sleeping. Examination of care plans identified different levels of information recorded by different members of staff, most care plans regarding sexuality had not been appropriately completed, one residents care plan had not been updated with information from the speech therapist, and two residents care plans for sleeping did not include that the individuals sleep on specific air mattresses. Records of residents weight are recorded, one residents weight record included actions to be taken by staff when a weight loss was noted, however a further weight loss did not indicate that staff should take any further actions. One residents care plan did not contain information regarding a wound on the Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 11 individuals arm. One resident’s care plan contained good information regarding the individual’s social needs. Medication was found to be appropriately stored with the exception of two items which were not stored as per the manufacturers instructions. The temperature of the medication fridge on the first floor has been recorded daily, however evidence was not available to confirm the actions staff have taken to ensure it is within the recommended range. Residents have access to a telephone at the home. Residents were appropriately dressed in their own clothing. Staff reported that medical examinations take place in resident’s own bedrooms. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 & 15 Residents are encouraged to make choices in their daily living regarding activities and meals. Resident’s dietary needs are met with a varied menu, which caters for medical and religious diets. EVIDENCE: Residents have access to a few regular activities at the home including an aromatherapist and artist who visit once a week, gospel singers who visit the home every other week, a film club which is held every month, a selection of books and games are available at the home. Residents comments regarding activities at the home included: ‘we had a good Christmas party last night’; ‘the entertainer was good yesterday’; ‘there could be a bit more going on here’; ‘I miss going out’; ‘there’s a lot going on around here, always busy’ and ‘I’d rather be here than on my own’. One resident said that they wanted to go out for a walk and had been told that it was too cold today. Two members of care staff co-ordinate activities at the home, however the employment of a dedicated activities worker would provide more activities and outings. Mealtimes are well organised and residents have time to enjoy their food. Staff are available to assist residents with eating, this was observed to be appropriately managed. Residents receive three meals a day with drinks and snacks available in between meals. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 13 Residents comments regarding the food included: ‘the meals are very good’; ‘the food seemed ok’; ‘the food is good’; ‘I like the food’ and ‘the food is lovely, good choice’. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Appropriate policies are in place to protect residents from harm. EVIDENCE: The organisation has a policy for the protection of vulnerable adults and a copy of the placing authorities policy for the protection of vulnerable adults is available at the home. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 15 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 Woodlands House provides a safe well-maintained environment for residents. The home is maintained to a good standard of cleanliness. EVIDENCE: The home was purpose built to meet residents needs. The home is found maintained to a satisfactory standard. All areas of the home were found to be clean and hygienic. Residents made positive comments regarding the hygiene levels at the home. The laundry is away from the kitchen and dining areas and is appropriately equipped. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 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): 27, 29 & 30 Staffing levels were observed to be appropriate to meet residents needs. Staff morale was high. Staff recruitment practices ensures the protection of residents. EVIDENCE: Residents and staff reported that there are sufficient staff available at the home. Most staff have worked at the home for a number of years and have gained knowledge and experience of residents needs. Residents comments regarding staff included: ‘staff are kind’; ‘staff are polite’; ‘staff are very good’; ‘there are enough staff around’ and ‘some staff are a bit bossy’. Staff files are retained at the home with some information held at the organisations head office. Staff files examined contained a photograph of the individual, proof of identity, two written references, confirmation that Criminal Records Bureau checks have been completed, appraisals and training records. Staff training records examined indicated that one member of staff had not completed any training during 2005. Staff reported that they have access to training and have completed training in food hygiene, manual handling, health and safety and dementia care. All staff must complete training in dementia care and staff who are designated to supervise other staff must complete training in supervision. Nurses reported that they have not completed training recently and they should have access to relevant training to keep up to date with their nurse registration. Woodlands House DS0000034082.V274121.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): 31, 36 & 38 The manager works with staff to provide a good standard of care at the home. Systems are in place for staff to receive supervision, however all staff have not received regular supervision. Residents and staffs health and safety are protected by policies in place, however the practice and recording regarding the fire alarm system are inadequate. EVIDENCE: The manager has been at the home for over three years and has previous experience working in similar services. The manager demonstrated a commitment to providing good quality care to residents. Staff made positive comments regarding the way the home is managed and the support that they receive from the manager. Staff supervision structures are in place at the home, however not all staff have received regular supervision. Staff receive annual appraisals and these records are maintained on staff files. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 18 The manager reported that the systems in place for recording the regular tests of the fire alarm have changed, the records identified that two fire drills have taken place and daily checks are made on the building and the fire escapes, however the weekly test of the system has not been completed as required. Woodlands House DS0000034082.V274121.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 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 2 X 2 Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 20 YES Are there any outstanding requirements from the last inspection? 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)& (2) Requirement The registered person must ensure that care plans include details so staff can meet residents assessed needs. (previous timescale of 30/06/05 not met) The registered person must ensure that appropriate records are maintained of wounds and pressure sores. The registered person must ensure that the fridge temperature on the nursing unit is maintained within the recommended range. (previous timescale of 13/06/05 not met) The registered person must ensure that staff are employed to provide a variety of appropriate activities and outings for residents. (previous timescale of 30/06/05 not met) The registered person must ensure that nurses receive appropriate training. (previous timescale of 30/06/05 not met) DS0000034082.V274121.R01.S.doc Timescale for action 06/02/06 2. OP8 15 (1 & 2) 06/02/06 3. OP9 13 (2) 06/02/06 4. OP12 12(1)& 16(2) n 06/02/06 5. OP30 18 (1) c 06/02/06 Woodlands House Version 5.1 Page 21 6. OP30 189 (1) 7. OP36 18 (2) The registered person must ensure that all staff complete training in dementia care and for senior staff to complete training in supervision. The registered person must ensure that all staff receive supervision at least six times a year from a senior member of staff at the home. (previous timescale of 30/06/05 not met) 06/02/06 06/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP9 Good Practice Recommendations The registered person should ensure that staff date and sign all records. The registered person should ensure that medication is stored as per the manufacturers instructions. Woodlands House DS0000034082.V274121.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 House DS0000034082.V274121.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. 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