Inspection on 16/10/06 for Woodlands Residential Care

This inspection was carried out on 16th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Woodlands Residential Care 31/10/08

Woodlands Residential Care 07/03/06

Woodlands Residential Care 28/11/05

Woodlands Residential Care 07/02/05

Woodlands Residential Care 23/08/04

Woodlands Residential Care 01/02/04

Woodlands Residential Care 10/09/02

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

CARE HOMES FOR OLDER PEOPLE Woodlands Residential Care Wood Lane Liverpool Merseyside L27 4YA Lead Inspector Andrea Morris Key Unannounced Inspection 16th October 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 Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 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 Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Residential Care Address Wood Lane Liverpool Merseyside L27 4YA 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) 0151 498 4266 Mr J Leggett Yvonne Moore Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Woodlands is a residential care home registered with the Commission for Social Care Inspection to provide accommodation and personal care for 29 Older persons. The home is privately owned. Woodlands is located in the Netherley area of Liverpool and have easy access to bus routes and local amenities. The home is a large Victorian house set in three and half acres of woodland and gardens. A programme of modernisation and refurbishment has been carried out to ensure facilities in the house and garden is accessible to residents. Accommodation is supplied by a mixture of single and double rooms, 14 of the rooms are en-suite. There are 3 lounges and a dining room. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection which took place over 5 hours. During the inspection the inspector spoke with residents, staff, the manager and the proprietor. A selection of documentation was examined including resident care files, staff personnel files, certificates relating to Health and Safety as well as training records and complaints file. What the service does well: What has improved since the last inspection? 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 Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 6 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 Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Residents are only admitted to the home following a full assessment of their needs; this assists to promote resident safety. EVIDENCE: The homes statement of purpose and service user guide remains unchanged. It is available upon request from the main office, all new residents and their families are provided with a copy of each to ensure they are aware of the service the home provides. All residents admitted to the home receive a written contract, this clearly defines the terms and conditions of residency. There are plans for the contract to be reviewed in the forthcoming months to ensure it remains adequate. The home manager carries out pre-admission assessments. Residents are only admitted following a full assessment of their needs, this assists residents are only admitted where their care needs can be met. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 8 Potential residents are encouraged to visit the home with their relatives, they are able to visit unannounced, if they prefer they can arrange to stay for a morning or afternoon to assist with their decision-making. Staff as required to seek advise from a variety of professionals, such as Tissue Viability Nurse, District Nurse, GP and social workers, all visits are recorded in the resident care file. The home does not provide intermediate care. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 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): 7, 8, 9, 10, 11 Care plans and risk assessments are well documented and kept under close review; this assists to ensure care remains appropriate and resident safety is promoted. EVIDENCE: All residents admitted to the home are in receipt of written care plans, these are recorded and reviewed on a monthly basis. All residents are assessed for potential risks, staff complete written risk assessments, which are reviewed, on a monthly basis. The homes medication was reviewed and found to be correct, staff record all medication received into the home and all return medication is accounted for. Stock is well controlled and no excess stock is held in the home, all records relating to medication were completed in full. However it was noted that staff were not recording the dates of opening short life medication, a recommendation has been made to address this issue. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 10 Residents who spoke with the inspector spoke highly of all staff members, residents commented on the professionalism of staff and their friendliness and the willingness to put themselves out. During the tour of the home staff were noted to have a good rapport with all residents, staff only entered a residents room following knocking on the door. The policy relating to care of the dying remains relevant, recently two staff have attended external training on care of the dying. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 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): 12, 13, 14, 15 Meals are well balanced and nutritious, these assist to promote a healthy lifestyle for all residents. EVIDENCE: The home employs an activities organiser for 24hours per week. A variety of activities are provided for residents on a daily basis. Activities are recorded daily on the notice board outside the dining room. Forthcoming activities are displayed in the main entrance area of the home, there are plans being made for Halloween and several activities planned for the Christmas period. There are currently new resident activity care plans being created by the activities organiser to ensure all residents are able to benefit from social arrangements. The home actively encourages residents to remain in contact with the local community, the Roman Catholic Church visits weekly to provide communion for those residents who want it. The Church of England visits upon request. The home also provides visiting entertainers. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 12 The home operates an open visiting policy for all visitors, residents confirmed they can receive visitors in private and staff members treat all visitors with respect. Residents stated they could choose how they spend their day, some residents prefer to spend time in private in their room, residents said the staff respected their decisions made. The home operates a four weekly menu rota. Menus are constantly reviewed and amended if residents do not like the options available. Any resident can make alternative choices to the two daily options and these are provided. All residents who spoke with the inspector identified they enjoyed all meals and confirmed they could choose alternatives. The kitchen was found to be well organised and stock was managed well. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 13 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, 17, 18 Staff receive regular training in adult protection; this assists in promoting resident safety. EVIDENCE: The home complaint file was examined, the home records complaints received and the action it takes to rectify the issues raised. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. The home assists residents to maintain their legal rights by displaying information on independent advocacy agencies, residents are able to access the information independent from the home. All staff except the new staff have completed the adult protection training, there are plans for all remaining staff to complete the training by the end of November 2006. There has been no incidents of adult protection since the last inspection. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 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): 19, 20, 21, 22, 23, 24, 25, 26 Residents’ rooms are personalised with their own effects, thus assisting in creating a homely atmosphere. EVIDENCE: The home is well maintained, new lighting was installed throughout the home to create a soft but effective lighting effect. All communal areas are maintained to a high standard, many resident rooms have views of the large gardens. The gardens are maintained to a good standard, the perimeter fencing is currently being replaced in sections to ensure safety is maintained. The home has since the last inspection purchased two new hoists, to assist in the safe handling of residents. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 15 Residents enjoy their own personal space, all rooms are individual, residents are encouraged to bring in personal items to ensure they feel at home. Residents’ rooms are kept clean and maintained to a good standard, rooms are decorated as needed to ensure the standard is maintained. The home was found to be very clean and free from any unpleasant odours. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The home operates a robust recruitment process. All staff are thoroughly checked, this assists in safeguarding residents from potential harm. EVIDENCE: The home is generally well staffed, and does not use agency staff, this assists in promoting continuity of care. The staff rotas were examined and it was found the home was well staffed. Staff receive regular training in a variety of care needs, recent training includes fire training, moving and handling, first Aid refresher training, bereavement, falls awareness, dementia, care induction. A sample of staff personnel files were examined, it was noted all staff were checked against the CRB (Criminal Records Bureau). All files contained the required information as listed in the National Minimum Standards. The home currently has 37.5 of care staff with a completed NVQ2 in care, there are currently 3 staff studying the programme and when completed this will bring the homes figure up to the 50 as required. The home operates a comprehensive induction programme, which is recorded and maintained within the staff file. The manager signs the induction programme to identify the completion of the work. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37, 38 The home is well managed by an experience and competent manager, this assists in promoting safe care practices to all residents. EVIDENCE: The manager is registered with the Commission for Social Care Inspection, she holds the NVQ4 in management. The manager is experienced and competent in managing staff and providing leadership to the team. The team is very settled, the staff provide a friendly and positive environment, residents commented that they were happy with the manager and the staff employed within the home. The home carries out its own quality assurance surveys, questionnaires are sent out annually to residents and their families to report on the homes Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 18 performance, comments are recorded and action plan devised if appropriate to address issues raised. A questionnaire is also forwarded to visiting professional personnel such as GP and nurses to also seek their opinion of the home. The manager is currently seeking to develop the quality assurance further by recently setting up weekly meeting/reviews with residents individually. This is to monitor their feelings of the home as well as to record their general wellbeing. An audit tool is currently being drafted to assist in the monitoring of meals within home, plans for this to be implemented are by the end of November 2006. All staff receive supervision on a regular basis from their line manager, evidence of the supervision is recorded in the staff files. Staff receive supervision at least 6 times per year as required in the National Minimum Standards. The home ensures all its policies and procedures are kept under regular review, policies and procedures are kept in the main office so staff can access them accordingly. The certificates relating to Health and Safety were viewed and all found to be in date and adequate. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 N/A N/A 3 3 3 Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 20 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 OP9 Good Practice Recommendations Staff must record the dates of opening on all short life medication to ensure the safety of residents is maintained. Woodlands Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Residential Care DS0000025386.V311510.R01.S.doc Version 5.2 Page 22 - 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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