CARE HOMES FOR OLDER PEOPLE
Woodlands Manor 21-23 Chambres Road Southport Merseyside PR8 6JG Lead Inspector
Daniel Hamilton Unannounced 10 August 2005
th 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 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 Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Woodlands Manor Address 21-23 Chambres Road Southport Merseyside PR8 6JG 01704 554848 Telephone number Fax number Email 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 Manor Ltd Lyndsey Emma Dee Care Home 27 Category(ies) of DE - Dementia registration, with number OP - Old Age of places Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service must employ a suitably qualified and experienced manager who is registered with the CSCI. 2. No service users can occuppy rooms on the second floor until such a time as the Commission for Social Care Inspection is satisfied that they are suitable for occupation. 3. Until such time that a lift serves the second floor, the rooms once converted may only be used by ambulant service users. 4. No further service users within the OP category may be admitted into the home Date of last inspection 11th January 2005 Brief Description of the Service: Woodlands Manor is a privately owned care home which is registered to provide personal care and support for up to 19 older people or a maximum of 27 older people with dementia. The home consists of two large houses joined together by a central link and is situated in a quiet residential area, not too far from the centre of Southport and all its amenities. Public transport is available close by. The home has three levels. The basement and ground floor are serviced by a passenger lift. The communal areas in the home consist of two lounges, one of which is attached to a conservatory and a dining room. The home is equipped with a hoist and assisted bath and toilet facilities are located throughout. A call bell system with an alarm facility is fitted in each bedroom and also the communal areas. There is a large garden to the rear which is well maintained. Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8.5 hours. It was an unannounced visit and conducted as part of the regulatory requirement for care homes to be inspected at least twice a year. There had been no cause for any visits to the home since the last routine inspection in January 2005. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The owner and manager, 2 staff members and 7 of the 18 residents were spoken to during the visit and their views obtained of the home. There had been a change of owner and a new manager appointed since the last inspection. Some of the findings identified during the inspection had been inherited by the new owner and manager, who demonstrated a commitment to improving the home’s environment and the overall service provided. What the service does well: What has improved since the last inspection?
Two bedrooms had been fitted with new carpets following a requirement at the last inspection. The new owner and manager were in the process of improving systems and had introduced new policies and procedures. A maintenance plan had been developed with a view to improving the environment for residents over a period of time.
Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 standard(s) 3 Some of the home’s pre–admission assessments had key information missing. Without a full assessment, there is no assurance that care needs will be met. EVIDENCE: Three assessments were viewed during the visit. Two were for people who had moved into the home since the last inspection (one for respite care and the other for long-term care) and one was for a resident who had lived in the home for over seven years and whose needs had recently changed. The manager had introduced a new pre-admission assessment form to improve the home’s assessment process. Although the assessment forms were well constructed, some assessment information was only partly completed and key information including; current health, medication, history of falls, oral health and foot care had not been recorded. Furthermore, some assessment paperwork had not been dated or signed. Assessments completed by social workers were also available on two files. The manager confirmed that the information generated from the assessment process was used to develop a plan of care for each resident.
Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 standard(s) 7, 9 and 10 Care plans were not in place for all residents and medication records were not being appropriately maintained. This practice could place resident’s health and safety at risk. Residents were pleased with the standard of care provided and confirmed their privacy, dignity and rights were respected. EVIDENCE: Since the last inspection, the manager had introduced a new care plan system. Three files were viewed. Two files did not contain a plan of care to ensure that all aspects of the resident’s health, personal and social care needs were identified and planned for. The one care plan viewed was completed to a good standard and clearly identified the resident’s needs and the support required by staff to meet them. Supporting documentation including; risk assessments, health records and daily report sheets were also maintained. The home had a medication policy in place to provide guidance to staff and a record of staff authorised to handle medication, sample signatures and photographs of residents were stored on file. Two residents self-administered their own medication and had signed disclaimers without a risk assessment having been completed by the home. Medication administration records were also checked. Some medication records had not always been signed to confirm the administration of medication and
Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 Page 10 there was no record of medication being checked, signed for and dated upon entering the home. Likewise, one medication record did not detail the date that medication was administered. Residents spoken with during the visit were satisfied with the standard of care provided. Comments included: “I am well cared for, I can’t grumble at all”; “I am treated very well and the staff are very caring” and; “I think the staff care for us very well”. Staff spoken with during the visit demonstrated a good understanding of how to respect the rights of people living in a group care environment. Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 standard(s) 13 and 14 Residents retained control of their daily lives in order to maintain their independence, relationships and preferred lifestyles. EVIDENCE: Residents reported that they were able to have visitors at any reasonable time and that they could maintain links within their local community. One resident spoken with said; “The home has no restrictions on visiting times.” Another resident stated; “I go out and visit friends, attend church services and live life as I choose.” Residents spoken with confirmed that they were supported and encouraged to make choices and retain control of their own lives. Comments from four residents included; “I control my own life and please myself what to do each day”; “We are given the choice to do our own thing”; “I am capable of doing many things for myself and I am able to maintain my independence” and “Noone controls you here. Everyone is an individual in their own right and respected accordingly.” Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 standard(s) 16 and 18 There had been no complaints since the last inspection and residents were confident that if they needed to make a complaint, their concerns would be listened to and acted upon. Safeguards were in place to protect residents from abuse. EVIDENCE: The manager had introduced a new ‘Complaints, Suggestions and Compliments Policy’ since the last inspection. Furthermore, a service users’ handbook had been developed, which contained details of ‘Making a Complaint and giving Compliments.’ The home’s complaints book was viewed which showed that no complaints had been received since the last inspection. All residents spoken with had no complaints about home and were confident that staff would deal with any issues should they arise. One resident said; “The new manager is smashing and always listens to us” and another reported; “I have no complaints about the home. If had a complaint I would be listened to.” The home had a number of policies and procedures in place to protect residents from abuse. These included an ‘Avoidance of Abuse’; ‘Whistle blowing’ and the local authority’s adult protection procedures. Although records showed that only four staff had completed Abuse training, staff spoken with during the visit had a good knowledge of the different types of abuse and their responsibility to protect the welfare of the people living in the home. Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 standard(s) 19 and 26 Plans were in place to repair, redecorate and refurbish the home over a period of time, to improve the environment for residents. The home was clean, and comfortably furnished and the comfort of residents was not compromised. EVIDENCE: Some parts of the home were in need of refurbishment and redecoration. The new owner and manager had produced a maintenance plan to address priority work including: the installation of a ramp at the front entrance; to redecorate the entrance hallway, lounge and dining room; to fit radiator covers and to redevelop the 2nd floor. A new side gate and fencing had been fitted and paper towels and holders had been fitted in the home. Ongoing work requiring attention by the home’s handyperson was clearly documented and records maintained. Some parts of the home were not fitted with water temperature valves and this was brought to the attention of the manager. Repair/ refurbishment work identified at the last inspection had been completed. All areas viewed were clean and hygienic. A new cleaner had commenced employment since the last visit and domestics were observed to be cleaning
Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 Page 14 the home. Residents reported that the home was much cleaner since the new owner had taken over. One resident said; “The home is much cleaner than it used to be. The domestics are excellent.” Another resident stated; “The home is exceptionally clean.” Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Sufficient numbers of staff were deployed to meet the needs of residents. Preemployment checks had not been appropriately completed to safeguard the people living in the home. Some staff had not received the necessary training to ensure competency in their role. EVIDENCE: Examination of rotas, direct observation and discussion with residents verified that the home was staffed with one senior care assistant and two carers during the day, with one waking night staff and an additional member of staff providing a sleep-in service through the night. The manager worked from 9.00 am to 5.00 pm during weekdays and confirmed that staffing levels were being closely monitored, due the needs and numbers of residents increasing. At the time of the visit, the home had a vacancy for a weekend and full-time cook. Residents spoke highly of the staff team. Comments included: “I am treated very good by the staff”; “There are always three staff on duty during the day. I think there are enough staff on duty to meet our needs” and; “I think the staff are great. They are always there for you.” Three new staff had commenced employment since the last inspection. Recruitment records showed that all three staff had commenced employment without a Protection of Vulnerable Adults (POVA) check. Original copies of Criminal Record Bureau (CRB) certificates were not on file. One file viewed did not contain any of the information required under the Care Home Regulations. Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 Page 16 Staff spoken with confirmed that they had received induction training however only two of the staff files viewed contained a record of induction. The manager was in the process of updating all staff files to include a record of training completed. The home’s training matrix showed that a number of staff had not completed all safe practice training and that some were in need of refresher training. Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Some important records were not in place or being appropriately maintained, to safeguard the health, safety and welfare of residents and staff. EVIDENCE: Service / maintenance certificates were available within the home for: electrical wiring, PAT testing, hoists, the lift and fire extinguishers. The certificates were out-of-date for gas safety and the fire alarm system. Fire records detailed that the last recorded fire test was 18/5/05 and showed that night staff were not receiving fire instruction training at the recommended intervals. Likewise, the emergency lighting and fire extinguishers were not being visually checked on a monthly basis. The last recorded fire drill was 7/07/04. Generic and fire risk assessments had been completed and the home had a health and safety policy in place. There was no record of water temperature checks being carried out and a legionella risk assessment was not in place.
Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 2 Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 Page 19 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. 2. 3. Standard 7 9 9 Regulation 15 13 (4) 13 (2) Requirement Each resident must have a plan of care. A risk assessment must be completed for residents who selfadminister their medication.. Staff must sign medication records following the administration of all prescribed medication and the correct codes must be used when applicable.. All medication entering the home must be checked, signed in and dated on the medication administration record. Staff must only be confirmed in post if full and satisfactory information has been obtained via a POVA check and a CRB has been applied for.. All staff records must be brought up-to-date in accordance with the Care Home Regulations [Previous timescale of 28/02/05 not met). Safe practice training must be completed by all staff and refresher training must be completed periodically.. The fire alarm system must be tested on a weekly basis and records maintained.. Timescale for action 10/9/05 10/09/05 10/09/05 4. 9 13 10/09/05 5. 29 19 10/09/05 6. 29 19 10/11/05 7. 30 18 10/12/05 8. 38 23 (4) 10/09/05 Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 Page 20 9. 38 23 A gas safety and fire alarm service certificate / record must be forwarded to the Commission 10/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 3 19 Good Practice Recommendations Pre-admission assessments should be completed in full and detail all the needs of residents. The absence of thermostatic valves in some areas of the home should be risk assessed as a matter of urgency for each resident and installation work prioritised according to the level of risk identified.. Night staff should receive fire instruction training every three months. The emergency lighting and fire extinguishers should be visually inspected on a monthly basis and records maintained. A legionella risk assessment should be completed 3. 4. 5. 38 38 38 Woodlands Manor 20050808 Woodlands X10015 UN Stage 4 S64444 V242324 F53.doc Version 1.40 Page 21 Commission for Social Care Inspection Burlington House Crosby Road North Waterloo, Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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