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Inspection on 10/01/06 for Woodlands Nursing Home The

Also see our care home review for Woodlands Nursing Home The for more information

This inspection was carried out on 10th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The assessment documentation is of good quality this helps ensure that all the residents` health and social care needs are identified and met. The home provides a good standard of care, which is evident to see in the presentation of the residents as well as their and the staffs comments. The staff is well motivated and several have been working in the home for some years. The manager has an open and inclusive style, which was evident to the inspector and in conversation with the staff.

What has improved since the last inspection?

The refurbishment programme has provided the residents with a significantly improved standard of accommodation and associated facilities. The reduction in shared bedrooms to one only has improved the level of privacy for the residents. The manager has improved communication within the home through the introduction of residents and relatives meetings.Greater emphasis has been placed on staff training and an expansion of social activities including hand massage is appreciated and was commented on by the staff to the inspector. The Requirements and Recommendations made at the previous inspection have been addressed.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home The 8-14 Primrose Valley Road Filey North Yorkshire YO14 9QR Lead Inspector John McGarva Unannounced Inspection 10th January 2006 09:30 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 The DS0000061590.V274473.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 The DS0000061590.V274473.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home The Address 8-14 Primrose Valley Road Filey North Yorkshire YO14 9QR 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) 01723 513545 Hexon Limited Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4 / 08 / 05 Brief Description of the Service: The Woodlands is a large detached property set in secluded gardens approximately 2 miles from the seaside town of Filey and 8 miles from Bridlington. It is registered to provide personal and nursing care for up to 34 older people. The property is on three floors including ground floor and there are two vertical lifts providing level access to all areas. Major refurbishment and alteration of rooms has just been completed to reduce the number of shared rooms to one. Most of the rooms have en-suite toilet facilities. The grounds to the east of the property are of good size and wheelchair access is possible and further improvement in access is proposed for the future. Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection, which took place on Tuesday 10th January 2006 and the proposed manager Mrs Judith Lucas and Mrs Christine Reeve, general manager for Hexon Ltd the owners were available to assist with the process. The inspections commenced at 9.30 hrs and finished at 13:00 hrs a total of 3.5 hrs. There were 24 residents in the home who required nursing care and one who was in receipt of social care only. The inspection focused on issues raised at the last inspection. An inspection of some of the resident’s rooms, lounges and bathrooms took place at a previous visit in November 2005. Discussions took place with the manager and care staff and residents. The residents appeared well pressed and dressed and several were receiving the attention of the hairdresser during the inspection. What the service does well: What has improved since the last inspection? The refurbishment programme has provided the residents with a significantly improved standard of accommodation and associated facilities. The reduction in shared bedrooms to one only has improved the level of privacy for the residents. The manager has improved communication within the home through the introduction of residents and relatives meetings. Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 6 Greater emphasis has been placed on staff training and an expansion of social activities including hand massage is appreciated and was commented on by the staff to the inspector. The Requirements and Recommendations made at the previous inspection have been addressed. 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 The DS0000061590.V274473.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 The DS0000061590.V274473.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): 2, 3 and 6. The service user guide includes all information required by the standard. The resident’s needs are assessed and met in a professionally planned manner. EVIDENCE: The details of how the residents can access the CSCI have now been included in the service user guide in accordance with advice given at the last inspection. The assessments are now dated and signed by the assessor and although there is no designated place for the resident or relative to sign to indicate their involvement in the process, where this has occurred, a signature is appended at the foot of the assessment sheet. Routine weighing of the residents takes place where indicated and new documentation utilising the ‘Malnutrition Universal Screening Tool’ (‘ MUST ’) has been introduced to help monitor those at risk in this regard. The home does not provide intermediate care. (Standard 6) Woodlands Nursing Home The DS0000061590.V274473.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): 9 and 10. The physical and health needs of the residents are identified and appropriate care plans are created to ensure they are met. The storage and management of medications is satisfactory. EVIDENCE: The residents looked well cared for with clean and well-pressed clothes and those spoken to were very happy with the care they were receiving. The care plans inspected demonstrated that there was ample information on which to ensure that all their needs and wishes were addressed. There is no designated place for the resident or relative to sign to evidence that they have seen and been consulted about the care plan but signatures are appended at the foot of the individual problem sheets where such consultation has taken place. In practice, few relatives or residents are interested or able to take part in this process. The storage and management of the medications is satisfactory with suitable policies and procedures available to see. Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 10 Access to the medication room is through a glass-panelled door and the room is of sufficient size, layout and lighting so as to assist the nurses and help ensure safe practice. There are two systems in place involving: 1. A monitored dosage ‘Manrex’ blister pack system (MDS) prescribed from the Humanby GP practice. 2. Administration from packs or bottles prescribed and dispensed from the Filey based GP practice. This can complicate the job of the nurses who administer the medications but the manager said that the two systems were working satisfactorily despite this. The controlled medication stocks for one resident was checked against the records and found to be correct. The drug refrigerator was in need of defrosting. There are plans to relocate the hairdressing from a lounge to an area just off another lounge into what is at present access to a toilet. Woodlands Nursing Home The DS0000061590.V274473.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): This standard was not inspected on this occasion. EVIDENCE: Woodlands Nursing Home The DS0000061590.V274473.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): 16 and 18. The production and display of a relevant complaints procedure and staff’s good knowledge of adult protection issues safeguarded service users from abuse. EVIDENCE: The home has a complaints policy with time-scales for the resolution of these and this is on display at the entrance to the home. There are clear Adult Protection and Whistle Blowing procedures available to protect the residents. The care staff is aware of how to detect abuse and what to do should an occurrence take place. Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This standard was not inspected on this occasion. EVIDENCE: Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 14 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 and 28. The residents receive a good standard of care from sufficient staff who are appropriately trained and supervised. EVIDENCE: The home complies with the staffing letter of the previous regulatory authority and the past problems of recruitment have been addressed since the last inspection. Six of the care staff has achieved NVQ Level 2 standard and three have achieved NVQ Level 3. Five of the staff has started NVQ Level 3 training and one Level 3 carer has now embarked upon NVQ Level 4 training. In total, 80 of the existing care staff has NVQ qualifications, which exceeds the minimum standard of 50 , set by the CSCI. Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 15 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, 32 and 38. The home is well managed with staff that is kept informed and consulted on developments in the home. Development of care policies & procedures and easy to find indexing is indicated. EVIDENCE: The Manager is a first level nurse with many years of experience in caring for the elderly and has commenced the NVQ Level 4 in management. Her application to be the registered manager has not yet been completed. Staff spoken to confirm that the manager has an open consensual approach and that regular meetings are held with staff to keep them informed about changes or developments in the home. Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 16 Regular statutory training takes place in the areas of Fire Safety, Moving & Handling, Adult Abuse and First Aid. The home’s policies and procedures need to be reviewed and in particular a comprehensive policy on bathing must be written and should include: • • • Filling the bath with hot water and checking the temperature using a thermometer, ensuring it is no more than 43 degrees centigrade. Lowering of the resident into the bath using appropriate hoisting equipment. Never to leave the residents in the bathroom alone. The clinical or care policies should be separated from administrative and personnel policies and should be numbered, indexed and dated. Signatures of all care and nursing staff should be obtained to evidence that they have seen and understood the homes policies. Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 17 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 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 3 17 x 18 3 x x x x x x x x STAFFING Standard No Score 27 3 28 4 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x x x x x 2 Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard 38.5 Good Practice Recommendations All care policies and procedures should be kept separately. All policies should be numbered, indexed and dated. The signatures of all care staff should be obtained to evidence that they have seen and understood the policies. Woodlands Nursing Home The DS0000061590.V274473.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 The DS0000061590.V274473.R01.S.doc Version 5.1 Page 20 - 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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