Inspection on 28/11/05 for Woodlands Residential Care

This inspection was carried out on 28th November 2005.

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 16/10/06

Woodlands Residential Care 07/03/06

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 Unannounced Inspection 28th November 2005 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 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.V269420.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2005 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 are 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 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.V269420.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection that took 4 hours. During the visit the inspector spoke to residents, staff, the manager and the proprietor. A sample of documentation was examined including residents’ care files, staff personnel files, fire book and health and Safety certificates. 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.V269420.R01.S.doc Version 5.0 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.V269420.R01.S.doc Version 5.0 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 following full assessment of there needs, this ensures the residents’ safety and interests are protected. EVIDENCE: The Statement of Purpose and service user guide were seen and found to be concise and easy to read. A copy is available upon request from the office. All residents admitted to the home are in receipt of a written contract, this clearly identifies their terms and conditions of admission. The manager carries out a pre-admission assessment to ensure the needs of each individual can be met. Potential residents are encouraged to visit the home prior to admission. Individual records are maintained and a number of records were examined of residents who had most recently entered the home. Assessment of needs was available then all residents are assessed on a regular basis. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 Page 8 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 therefore assisting with safeguarding the residents. EVIDENCE: Individual care plans are in place, all aspects of personal and social care are included. Evidence was seen that care plans are reviewed on a monthly basis. Each individual file contained detailed information of the residents’ working and social life to assist the staff in assessing the needs in detail. Evidence was seen of all multi-disciplinary personnel visits being recorded. The home has links with a regular chiropodist, hairdresser and other health care professionals including the District Nurse team. Medication is well organised, staff who handle medication have received external training and medication was found to be well managed. All medication with a short shelf life was dated on opening and fridge temperatures were recorded daily. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 Page 9 All residents who spoke to the inspector stated they had their privacy and dignity maintained by all staff. Residents receive their mail un-opened unless consent to open mail has been signed. The home has an adequate death and dying policy. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 Page 10 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 Activities are arranged well to ensure residents’ lives are balanced and fulfilled. EVIDENCE: The home employs an activities organiser for 20 hours per week. Residents stated they regularly enjoyed the activities provided, they also identified that staff respected their wishes when they chose not to participate. Activities are recorded in a book this allows the home opportunities to reflect and audit appropriateness. Residents during discussion stated they also enjoyed the outside entertainment, they have recently had a themed party and the Christmas party is planned for early December. The home maintains links with the local community; the Roman Catholic Church visits every Monday for Communion. Two residents attend the British Legion weekly. The home displays information in the reception area regarding accessing independent Advocacy links, a telephone is available for anyone to contact them for further details. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 Page 11 The Kitchen is well organised, menus were viewed and found to be well balanced. Residents informed the inspector they were able to have an alternative on a daily basis if they didn’t like the daily option. The kitchen stock was found to be well managed and evidence of fridge and freezer temperatures were recorded daily. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 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, 17, 18 The home has a good complaints procedure which helps safeguard and protect residents. EVIDENCE: The home has a complaints procedure that includes details of how to contact the Commission for Social Care Inspection. There is a clear audit trail of all complaints received in the home. Residents are supported if they wish to vote, most have chosen to use the Postal Vote system, any resident wishing to attend the local Polling Station would be helped to do so. The home has recently accessed external training on Adult protection for some staff. The home has also recently purchased a training video and written questionnaire so to use internally with all staff starting in early December 2005. Adult protection is also discussed during the initial induction training for all staff. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 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): 19, 21, 22, 23, 24, 25, 26 There have been some improvements to the decoration and lighting. This promotes a homely atmosphere for all residents who live in the home. EVIDENCE: The home has recently had new carpets throughout the corridors on the first floor including the entrance area fitted. New lighting and re-decoration is evident in many areas of the home. The proprietor informed the inspector that further re-decoration is planned for the New Year for the ground floor of the home. Most of the residents’ rooms were personalised and therefore aids the residents in feeling at home. The communal bathrooms and toilets were found to be adequate in number and suitable in decoration. There are large gardens and many residents had excellent views of the garden that are maintained to a high standard. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 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, 28, 29, 30 The procedure for recruitment is satisfactory and ensures all clients living in the home are safe and protected. EVIDENCE: The home is well staffed, rotas were examined and it was noted that all shifts were covered with very little need of agency staff. 40 of care staff has completed their NVQ2 training; further training is to be accessed in the New Year. There is a clear training matrix maintained by the manager. Training is accessed from local colleges as needed. A selection of staff personnel files were examined, a robust recruitment policy was being followed, evidence that staff were being appropriately checked and screened prior to employment being offered. Residents who spoke with the inspector identified that staff were both professional and helpful. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 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, 33, 36, 37, 38 The home is well managed; there is a strong sense of leadership, ensuring that the staffs are well directed to deliver a high quality care to residents. EVIDENCE: The Registered Manager is an experienced manager who has completed the Registered Managers Award. Staff spoken to stated that the manager was approachable and felt they had confidence in her. Residents also confirmed they were happy with the way the home was managed. The home has its own Quality Assurance system by which questionnaires are sent out annually. Meetings are held for residents and their families on a 3 monthly basis, the manager holds regular staff meetings to ensure all communications is maintained. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 Page 16 All staff are supervised and this is recorded. The manager carries out induction for new staff, this is detailed and covers all areas of care and Health and Safety. Certificates relating to Health and Safety were examined, several were found to have expired. The proprietor advised the inspector that he would ensure all would be addressed in the next few days. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 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 N/a 3 3 3 3 3 3 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 3 3 3 N/A N/a 3 3 2 Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? N/a 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 OP38 Good Practice Recommendations It is strongly recommended that all certificates are checked to ensure they are in date and available for inspection. Woodlands Residential Care DS0000025386.V269420.R01.S.doc Version 5.0 Page 19 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.V269420.R01.S.doc Version 5.0 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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