Inspection on 14/02/06 for Woodlands Nursing Home

This inspection was carried out on 14th February 2006.

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 Nursing Home 16/11/07

Woodlands Nursing Home 21/12/06

Woodlands Nursing Home 21/09/05

Woodlands Nursing Home 01/03/05

Woodlands Nursing Home 10/09/04

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 Nursing Home Gordon Road Ilford Essex IG1 1SN Lead Inspector Ms Gwen Lording Unannounced Inspection 14th February 2006 07:30 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 Nursing Home DS0000025966.V283397.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 Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Gordon Road Ilford Essex IG1 1SN 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) 0208 553 2841 0208 553 2946 Woodlands Total Care Nursing Home Limited Usha Patel Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Woodlands Nursing Home is registered to provide nursing care for up to 30 people over the age of sixty-five years. The large converted property is situated in a residential area of Ilford in the London Borough of Redbridge. There are good transport links and the home is close to shops and other amenities and community facilities. The majority of the rooms are single and some have en suite facilities. The bedrooms are located on three levels with access by lift to all floors. The home is able to accommodate people from different cultural and religious groups. The manager and some of the staff team have the ability to speak a variety of languages, and key words are taught to staff to facilitate care for residents whose first language is not English. The home is able to meet the cultural dietary needs of all residents. The home employs an activity co-ordinator, catering, laundry, domestic and maintenance staff. Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 7.30am. It took place over four hours during the morning. Discussion took place with the registered manager and several members of nursing and care staff. The Inspector spoke to several residents in the lounge, dining room and a number of residents who were in their rooms. A tour of the home was made and a number of care and staff records were looked at. This was the second statutory inspection visit in the inspection programme for 2005/2006. Over the course of the two visits, all key standards have now been assessed. The Inspector would like to thank the staff and residents for their input during the inspection. What the service does well: What has improved since the last inspection? Training in Adult Protection/ Abuse Awareness has now been extended to all staff working in the home, including the activity co-ordinator, ancillary and maintenance staff. Action has been taken to address some of the maintenance and refurbishment issues highlighted at the last inspection. Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 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 Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 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 Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 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): These standards were not tested on this visit However, evidence from the last inspection was that: • Appropriate pre-admission assessments are carried out for all residents prior to them moving into the home. Care plans are drawn up from the information in this assessment, ensuring that the needs of the residents are identified, understood and met. The home does not offer intermediate care. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 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): Standards 7, 8 and 9. Resident’s health and personal care are set out in individual care plans. The care plans are generally detailed but need to be more specific with regard to recording the outcomes for residents around the personal and social care needs of the individual. There are clear medication policies and procedures for staff to follow. Discussions with staff and review of medication records show that staff are following the policies and procedures to ensure that residents are safeguarded with regard to medication. Standard 10 was not tested on this visit. However evidence from the last inspection was that: • Residents are treated with respect and the arrangements for their personal care ensure that their right to privacy is upheld. EVIDENCE: The above standard was not specifically tested on this visit, as there were no outstanding requirements in relation to this standard. At the time of the last Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 10 inspection, all of the outcome standards were assessed as met. This standard will be re-tested at a future inspection. Individual care plans were available for each resident and the records of five residents were examined. The records for these residents were found to be generally detailed, but need to be more specific with regard to the recording of outcomes around the personal, social care needs and leisure activities of residents. Whilst residents appeared well groomed the care plans need to be more specific with regard to hair, nail and oral care. Some care plans did identify the need for oral hygiene but recordings in the care plan did not always show that such a task had been carried out. One resident had recently returned to the home from an in-patient stay in hospital. It was noted in the daily recordings that he had a small sacral pressure sore on re-admission to the home. However, this should have been recorded on the body map, which is included in the care planning documentation. The care plan of another resident indicated that he should have two hourly turns during the night, and whilst in bed for periods during the day. The turning chart was not being maintained accurately or up to date. Entries in daily recordings did not always relate to specific care plans and some entries made gave little indication of the actual care given. Comments made included: “Comfortable, all care given” The records showed that residents have access to other health care professionals such as dentists, chiropodists, GP’s and specialist nurses for example, Tissue Viability. It was evident from examining care plans that these are being reviewed on a monthly basis and updated regularly. However, it is recommended that care plans are re-stated on an annual basis and not just reviewed monthly, as some of these were last updated in late 2004 / early 2005. Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 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): Standards 12, 13, 14 and 15 were not tested on this visit. However, evidence from the last inspection was that: • The lifestyle within the home matches the expectations and preferences of residents and individual cultural and religious needs are understood and met. • The meals in the home are good and individual preferences and specialist dietary needs are catered for. • Visiting times are flexible and people are made to feel welcome in the home so that residents are able to maintain contact with their family and friends as they wish. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 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): The manager and staff make every effort to sort out any problems or concerns and makes sure that residents and their relatives feel confident that their complaints are listened to and will be acted upon. However, not all complainants would be able to follow up a verbal complaint in writing in line with the home’s existing policy/ procedure. All nursing and care staff have received training in Adult Protection/ Abuse Awareness. This has now been extended to all staff working in the home, including ancillary staff to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a complaint policy/ procedure and the records indicate the number of complaints received and includes details of the investigation, any action taken and the outcome for the complainant. The complaints procedure is also produced in three Asian languages i.e. Gujarati, Punjabi and Hindi. The home’s policy/ procedure states that all verbal complaints must be followed up in writing. However, some of the residents would not have the capacity to use a formal written process, nor would other complainants for example, relatives/ friends of residents. The home’s complaints procedure must be appropriate to the needs of all complainants. At the previous inspection a requirement was made for information in the complaints policy to be amended to include information for referring a Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 13 complaint to the Commission, at any stage, should the complainant wish to do so. There was evidence to show that the requirement has been met. At the previous inspection a requirement was made for training in Adult Protection/ Abuse Awareness to be extended to all staff working in the home, including the activity co-ordinator, ancillary and maintenance staff. Training records showed that this requirement has now been met. Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19 The overall atmosphere in the home is very welcoming, but there are still a number of areas requiring refurbishment and general maintenance, so as to provide residents living in the home with a well-maintained environment. Standard 26 was not tested on this visit. However, evidence from the last inspection was that: • All areas of the home were clean, tidy and free from odour throughout. EVIDENCE: At the previous inspection a number of areas in the home were highlighted for action with regard to maintenance, refurbishment and redecoration. Whilst some of these areas have been addressed, including the dining room and the top floor bathroom, all areas of the home must be adequately maintained to improve the comfort and safety of residents. For example both the bathroom/ toilet and disabled toilet on the ground floor are in need of redecoration and the floor covering needs to be replaced. The cupboard door was noted to be broken in the top floor bathroom and the coating on the handrails in one of the toilets (room 301) had peeled off exposing the metal beneath. Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 15 The home employs a maintenance person and the manager must ensure that there is an effective system in place for reporting minor repairs and maintenance issues. The registered providers must ensure that there is an ongoing programme of renewal for the fabric and decoration of the premises, which includes timescales and areas highlighted for priority action. A copy of this written programme must be provided to the Commission. Woodlands Nursing Home DS0000025966.V283397.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): Standard 30 Residents’ benefit from a committed staff team who have the skills and training to meet their needs. Standards 27, 28 and 29 were not tested on this visit. However, evidence from the last inspection was that: • Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. • The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: In discussion with the manager, staff and examination of training records it was evident that nurses and care staff have undertaken appropriate training in the care of older people. The registered providers employ a person specifically to undertake training for both nurses and care staff. There is a very comprehensive training programme for carers and qualified nursing staff. Topics for nursing staff include, wound care and pressure sore prevention, catheter care and drug administration. And for care staff include care of dentures, hair, nails and personal care. Plans are being discussed for all staff to undertake appropriate training in the care of people living with dementia. Woodlands Nursing Home DS0000025966.V283397.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): Standards 33, 35, 36 and 38 The manager ensures that safeguards are in place for those residents who lack capacity to manage their own financial affairs Standards 31 and 32 were not tested on this visit. However, evidence from the last inspection was that: • The manager is a very experienced and well-qualified person and residents benefit as the home is run in their best interests. EVIDENCE: Currently neither the manager nor the organisation acts as an appointed agent for any resident. Resident’s financial affairs are managed by their relatives/ representatives. The home has responsibility for the personal allowances of several residents. Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 18 Written records of all transactions are maintained, two signatories sign for each transaction and receipts are kept where necessary. Secure facilities are provided for the safe keeping of money and valuables held on resident’s behalf. A wide range of records were looked at, including fire safety, emergency lighting, accident/ incidents, Portable Appliance Testing (PAT), recording and regulation of water temperatures and risk of Legionella. These records were detailed, up to date and accurate. At the last inspection a requirement was made for the registered providers to ensure that the manager receives formal supervision on a regular basis. A system of peer supervision has been introduced and the manager stated that she is finding this very useful. Woodlands Nursing Home DS0000025966.V283397.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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 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 2 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 3 X 3 Woodlands Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement All areas of the home must be adequately maintained to improve the safety and comfort of residents. (Timescale of 30/11/05 not met) The registered providers must ensure that there is an ongoing programme of renewal for the fabric and decoration of the premises, which includes timescales and areas highlighted for priority action. A copy of this written programme must be provided to the Commission by the stated timescale. Care plans need to be more specific with regard to the recording of personal, social care needs and leisure activities of residents. Where the record of turning regimes is indicated for a resident, these recordings must be accurately maintained and up to date. The home’s complaint policy/ DS0000025966.V283397.R01.S.doc Timescale for action 30/04/06 2. OP19 23 30/04/06 3. OP7 15 30/04/06 4. OP8 12 14/02/06 5. OP16 22 30/04/06 Page 21 Woodlands Nursing Home Version 5.1 procedure must be amended so that it is appropriate to meet the needs of all complainants. 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 Nursing Home DS0000025966.V283397.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Nursing Home DS0000025966.V283397.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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