CARE HOMES FOR OLDER PEOPLE
Woodlands House 205 Woodlands Road Woodlands Southampton Hampshire SO40 7GL Lead Inspector
Annie Billings Unannounced Inspection 24th October 2005 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 House DS0000012161.V257337.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 House DS0000012161.V257337.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Woodlands House Address 205 Woodlands Road Woodlands Southampton Hampshire SO40 7GL 023 8029 2213 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) woodlands@compuserve.co.uk H W Group Ltd Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th May 2005 Brief Description of the Service: Woodlands House is a detached property set in extensive grounds in Woodlands on the edge of the New Forest. There is a bus stop outside the service, with links to Southampton, Totton and Lyndhurst, and a railway station is nearby at Ashurst. The home is owned by H W Group Ltd, who also own two other residential homes in Winchester and Bristol. Accommodation is arranged on two levels in the main house, with a single story extension called the cottage, attached by a covered walkway. Building work has recently been completed to provide a further four single rooms with en-suite facilities, and a passenger lift between floors. There are nine single rooms in the cottage and a further twenty five rooms in the main house, two of which can be used for shared occupancy. All rooms benefit from en suite facilities, aside from one room, which has a private bathroom close by. The home benefits from spacious communal areas. There is a lounge, library and garden room in the main house with additional seating outside the dining room, and a lounge in the cottage. Both living areas have a dining room and kitchen. There is also a small garden room off the main lounge with delightful views across the homes gardens. Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6.5 hours and was the second inspection of the year April 2005 to March 2006. Many of the core standards were inspected during the previous visit on the 10th May 2005; therefore referral to both reports will give a full overview of the service. A partial tour of the premises took place and observation of daily routines within the home. Care and other records were sampled. Discussions were held with eleven residents and four staff members. The acting manager, who is also the responsible individual of the service was available for the majority of the inspection. The home is currently without a registered manager. A manager has been appointed but has been delayed in taking up the appointment. Eight issues were raised as a result of previous inspections. The responsible individual and staff have made progress in addressing requirements and from discussions held, are committed to improve systems and procedures in the home. What the service does well:
Those residents spoken to said that, “staff are excellent”, “staff are very good, very helpful” and “they are like family”. Observation during the visit saw staff providing sensitive and caring support, and promoting independence. The home provides safe, clean, comfortable and homely surroundings, with a lot of attention to detail, with fresh flowers on dining room tables and other areas of the home, and well tended extensive grounds. People living at the home enjoy an independent lifestyle, and are offered choices in the same way as if they lived in their own home. Regular staff and residents’ meetings ensure they all have opportunities to be involved in the running of the home. Residents said that relationships with management are excellent, and that they are kept well informed and consulted about any changes within the service, although a number of people mentioned they missed having a manager in the home. It was necessary to move several residents from their room during the recent building works. As the home has a number of vacant rooms, residents have been given the option to move back to their original rooms or transfer
Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 6 permanently to alternative accommodation. All those spoken to are clearly glad that the building works have been completed, and contractors have left the site. What has improved since the last inspection? What they could do better:
Care plans need further development to ensure that staff receive detailed guidance on how to meet peoples’ needs. Risk assessments must be developed to ensure that any identified individual risks are minimised, and that the home does not present any unnecessary hazards to staff or residents. Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 7 Omissions were found on medications records, and the responsible individual has agreed to develop a signature chart to easily identify staff undertaking medication administration. Once this in place they will undertake regular audits of the records to ensure they are fully completed. Progress has been made in ensuring that recruitment records demonstrate that staff are suitably vetted. Files sampled for new members of staff identified gaps in the recruitment procedure. The home must ensure that recruitment procedures are tightened up, to ensure the safety of those living in the home. Training of staff has continued, and further dates have been set, but this must continue to ensure that staff have regular updates of mandatory training. A system has been developed to easily identify when training is due in the future. A new accident book has been supplied that meets the requirements of the Data Protection Act. Sampling of these records identified a need for more detail, and one accident had not been recorded. A system of auditing accidents has yet to be developed, although the responsible individual stated the home is purchasing a cushion lift, to ensure that residents are handled safely. Weekly and monthly fire test records were not up to date, and the last fire drill is recorded in July 2004, although a date has been set. This does not meet the requirements of the fire regulations and must be undertaken to ensure the safety of staff and residents. The maintenance person has been appointed health and safety representative for the home, but must undertake training before they assume responsibility. Both staff and management have an awareness of the areas that must continue to improve, and appear committed to do so, despite the difficulties of not having a full time manager. 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 DS0000012161.V257337.R01.S.doc Version 5.0 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 DS0000012161.V257337.R01.S.doc Version 5.0 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): 3, 6 A pre-admission assessment has been developed for new admissions to the home, but further detail is required to ensure that the home can meet peoples’ needs. The home does not offer an intermediate care service. EVIDENCE: Files were sampled of three recent admissions to the home. Basic preadmission assessments had been completed by a supervisor or the responsible individual (RI). The assessment process would benefit from further detail to ensure staff are aware of the need. One file sampled states the resident is selfcaring with personal hygiene, although a member of staff advised the need for washing their back and assistance with dressing. Another file had no assessment, and another “may need help”. One resident was identified as having a history of falls, but no risk assessment had been undertaken. This could lead to resident’s needs not being addressed, or residents at unnecessary risk. Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 10 The RI stated that the new manager intends to implement their own systems once they are able to take up their appointment, therefore no requirement has been made to develop this area further at this stage. The responsible individual advised that the home does not offer an intermediate care service. Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 11 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 Progress in the development of care plans was demonstrated, although more detail is necessary on some to ensure that staff receive sufficient guidance on meeting individual’s needs. Residents are protected by medication procedures in the home. EVIDENCE: Three care plans were sampled. One had no care plan. Another stated, “needs assistance in and out of the bath”, but gives no direction to staff on what or how to assist. Another states “no problems” for personal care, although discussion with a care assistant identified the resident needs help to wash and cream their back, and needs assistance with underwear. No mention of this was made in the care plan, although residents advised that all their care needs were well met by staff. Dependency profiles are carried out on a monthly basis to assess all aspects of daily living. Records are maintained of social activities undertaken by each resident, and evidence of monthly reviews and consultation with residents were seen. The recording system provides a risk assessment for nutrition, skin and pressure sores, although these are not always completed, as residents are
Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 12 largely self-caring. Other risks identified i.e. a risk of falling, or a need for moving and handling have not been risk assessed. Daily care records are good, with entries made for day and night time, including referrals to health professionals when necessary. Staff were observed providing caring support to service users, addressing and treating them with respect. Privacy and the promotion of independence were seen to be upheld. Since the last inspection, a pharmacy inspection has been undertaken at the home. New procedures had been developed, and records and storage of medication were found to be appropriate and no requirements or recommendations were made. Records sampled during this visit identified further omissions in signatures to confirm medication was administered or the reason for medication not being administered. This was discussed with the supervisor and the RI, who has agreed to undertake regular audits of these records. A sample signature list for medication administration was recommended, and a file set up of information on all medication used in the home, to allow staff to identify any symptoms of contra indications. The pharmacist is due to visit the home in November to provide staff training. Risk assessments and lockable storage tins were in place for long-term residents wishing to self medicate, but not for one on a short stay. The RI agreed to put this in place immediately. Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 13 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): None of these standards were inspected. EVIDENCE: Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 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): These standards were not inspected. EVIDENCE: Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 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 Resident’s benefit from living in a comfortable, clean and well-maintained environment, but the lack of risk assessments does not ensure the premises remain hazard free. EVIDENCE: Since the last inspection, building works have been completed, and contractors are no longer on site. All communal areas viewed were clean, comfortable and maintained to a high standard. A few bedroom windowsills were identified as needing repainting, and one bedroom carpet is discoloured in several areas. There are no immediate plans to address this, although the responsible individual has been made aware. Five new door closures have been fitted to bedroom doors, and a further five are due for completion in November. This has been done as an alternative to door wedges for those residents who prefer their door to remain open, to ensure their safety in the event of fire.
Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 16 A basement flood was identified during the inspection, and immediate action was taken to address this. Following investigation, the cause appears to be due to a building fault, and the matter was to be referred to the contractors. All bedrooms viewed were comfortable, and had been personalised by the occupants. Discussion with the responsible individual confirmed that residents are not provided with a lockable storage area. The RI agreed to offer all residents a suitable facility, and if refused, has agreed to record this on file. The laundry facility appeared well organised, and one resident described the service as “excellent”, although another suggested items “do go missing”. This problem had already been identified and is being addressed by labelling. A number of areas were identified as potentially putting residents at risk. Potentially hazardous cleaning and laundry products were found in the laundry area, and the RI agreed to have a lock put on the cupboard immediately. The key was also found in the cupboard used to store potentially harmful products used in the home, although this was removed immediately by the RI. Staff need to be reminded that these must be stored safely. Uncovered hot water pipes and a variety of rugs were identified in one resident’s room, a water system delivering boiling water in the cottage kitchen to which residents have free access and several tubes of steradent were seen in unlocked bedrooms. These areas need to be risk assessed to ensure the safety of residents, and appropriate action taken to minimise the risk as necessary. Bars of soap were seen in a number of communal areas. This is not good infection control practice, and the RI took steps to have these removed, and intends to have soap and towel dispensers fitted. The grounds to the property are extensive, and well maintained, providing residents with lovely views of wildlife and the surrounding area. Residents said this was a “source of delight” to many of them. One resident said they were very comfortable in the home, and another that “we have a very comfortable lounge”, and confirmed they were “very lucky to have such a large and comfortable room”. Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 17 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): 29, 30 Progress has been made in updating existing staff files, although information held on new staff does not demonstrate the recruitment process is robust to ensure the protection of residents, and that staff receive adequate training to meet their needs. EVIDENCE: Residents spoken with were keen to praise the staff team. Those residents spoken to said that, “staff are excellent”, “staff are very good, very helpful” and “they are like family”. Observation during the visit saw staff providing sensitive and caring support, and promoting independence. During the visit, relationships between staff and management were good, which helps promote a calm, friendly atmosphere in the home. Files were sampled of three members of staff recently employed. The RI advised of improvements to existing staff records, however three files of new staff members employed were incomplete. Two contained no application form or interview notes to demonstrate that gaps in CV’s, poor references or medical issues identified had been followed up. No evidence was available in one file to confirm their eligibility to work in the UK and a number of references were not dated, and one was not signed. Evidence was available to confirm that Criminal Records Bureau checks are undertaken for all staff. The RI intends to take up these queries with the human resources manager.
Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 18 Since the last inspection, a new induction training programme has been developed and is currently under trial with new staff. Minor alterations were agreed, to ensure that staff receive accurate information. The home has made progress updating staff training, although this has yet to be completed. Six staff have completed first aid training; twenty three have received training in fire safety; nine in the control of substances hazardous to health; three in food hygiene; four in moving and handling; eight in infection control; six in the prevention of falls; five in bowel care and five in health and safety. The RI advised of further courses already booked in fire safety, first aid, moving and handling, infection control and the protection of vulnerable adults. Training in continence and dementia were also discussed. Records of staff meeting minutes indicate that a number of staff are reluctant to undertake mandatory training courses. The RI is taking steps to address this. Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 19 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, 33, 35, 38 Residents’ finances are protected, and the home has taken steps to address shortfalls in promoting the health, safety and welfare of its residents and staff, but further work is necessary to ensure the home remains hazard free.. EVIDENCE: A new manager has been appointed, and it is expected they will take up their post in early December. The home is currently being managed by the responsible individual, Jo Gavin, who is committed to improving all areas of the home. Following consultation with residents and the Fire Safety Officer, five new bedroom door closures have been fitted, with another five being fitted next month. This is an alternative to door wedges identified at the last inspection, for those residents wishing to have their doors open, to ensure their safety in the event of a fire.
Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 20 Residents hold regular meetings, and are kept fully informed about the running of the home. Those spoken with are looking forward to having a new manager, although they advised they enjoy good relations with the RI. The RI advised that audits have commenced, and one has recently been completed in relation to menus and quality of food. This was in consultation with the residents. The supervisor advised that all residents manage their own finances, with the assistance of families. No personal allowances are held by the home. Discussion with the RI identified that inventories are not kept of furniture and items brought into the home by residents. It was agreed that these would be put in place. A new accident book has been supplied that meets the requirements of the Data Protection Act. Sampling of these records identified a need for more detail, and one accident had not been recorded. A system of auditing accidents has yet to be developed, although the responsible individual stated the home is purchasing a cushion lift, to ensure that residents are handled safely, and staff adhere to safe moving and handling techniques. The responsible individual advised that weekly and monthly fire test records were up to date, although evidence was not available to confirm this. The last fire drill is recorded in July 2004, although a date has been set and fire extinguishers were overdue for servicing. This does not meet the requirements of the fire regulations and action must be undertaken to ensure the safety of staff and residents. The maintenance person has been appointed health and safety representative for the home, but must undertake training before they assume responsibility. The home must ensure that potentially hazardous cleaning products are safely stored, medication recording procedures are adhered to, mandatory training is updated for all staff and any areas of potential risk to residents and staff are risk assessed and appropriate action taken to minimise risk to ensure the safety and welfare of residents and staff. Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 21 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 X 3 X X 1 Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 22 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 14 Requirement Care plans must reflect service users current and changing needs. Timescale of 31/05/05 not fully met. Reasons for the omissions of medication must be recorded. Timescale of 31/05/05 not fully met. Service users must be supported and protected by the home’s recruitment practices. Timescale for action 30/11/05 2 OP9 13 30/11/05 3 OP29 19 30/11/05 4 OP30 13, 18 Timescale of 31/05/05 not fully met. The programme of updating staff 31/12/05 in all areas of mandatory training including adult protection, health & safety, infection control, food hygiene and first aid must be completed. Timescale of 15/6/05 not fully met. All members of staff working in the home must receive fire training and drill practice,
DS0000012161.V257337.R01.S.doc 5 OP38 23 31/12/05 Woodlands House Version 5.0 Page 23 ensuring the safety of residents and staff is maintained. Timescale of 15/05/05 not fully met. Residents and staff must be protected by the risk assessment strategy in the home. This must apply to individual risk to residents, safe working practice i.e. Moving and handling, Coshh, infection control, and premises. The safety of service users and staff must be protected and promoted by providing a safe system of moving and handling service users and for recording and auditing accidents in the home. Timescale of 15/06/05 not met. 6 OP38 13 30/11/05 7 OP38 13 30/11/05 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 Standard Good Practice Recommendations Woodlands House DS0000012161.V257337.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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