Inspection on 26/05/05 for Woodlea

This inspection was carried out on 26th May 2005.

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

Woodlea 03/06/08

Woodlea 14/06/06

Woodlea 03/11/05

Woodlea 07/01/05

Woodlea 21/07/04

Woodlea 26/02/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE WOODLEA 61 Bawtry Road Bessacarr Doncaster DN4 7AD Lead Inspector Janet McBride Unannounced 26 May 2005 10:20 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. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodlea Address 61 Bawtry Road Bessacarr Doncaster 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) 01302 535441 01302 535483 WoodLea@fshc.co.uk Leeland Limited Jayne Ann Clark Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 07th January 2005 Brief Description of the Service: Woodlea is a care home providing residential care and accommodation for older people. The home is part of the Four Seasons healthcare group, and is located on Bawtry Road at Bessacarr, a suburb of Doncaster. The building is a converted residential property with an extension, providing twenty-six single bedrooms and four double rooms. The home is set in spacious well-established gardens that are easily accessible to service users, and is well placed for access to a supermarket, leisure centre, local pubs and the racecourse, and the town centre is a short ride away. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Woodlea Residential Home, which took place 26th May 2005,commening at 10.20 and finished at 16.30.Also a further visit to the home on 15th June 2005 at 20.50 hours. During the Inspection we looked at a chosen selection of the National Minimum Standards, sampling of records, document reading and care plans case tracked, also direct and indirect observation of staff interaction with service users. Individual and group discussions with service users took place, and feedback from relatives and visitors on the day. Comment cards were also left at the home for service users and relatives; some of these were received and are incorporated in this report. Any issues or concerns that were raised were discussed with the Manager at the time of Inspection, and verbal feedback session at the end of the day. What the service does well: What has improved since the last inspection? The manager and her staff worked hard at addressing the requirements made on the last Inspection that are within her control, they have either fully addressed the issues or progressing towards these being completed, and a hoist facility has now been purchased. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 6 Enthusiastic activities organiser who enjoys her role and tries to ensure that activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. 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. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 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 WOODLEA CS0000007982.V182775.R01.doc Version 1.30 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) 2 3 Current service users and prospective service users are not provided with a contract or statement of terms and conditions. New service users are admitted on the basis of a full assessment has been completed. EVIDENCE: No service users within the home have been issued with contracts/statement of terms and conditions and are not fully aware of the services and facility provided. Service users care plan that was case tracked provided evidence that a full assessment had been completed prior to admission from the placing authority, the home has competed various assessment of their needs, also relatives were asked to complete details of social background including hobbies and interests. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 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 Each service users receives health and personal care based on their individual needs, and is referred to any specialist services when required. EVIDENCE: Incident reports were discussed with the manager, and service users care plans were case tracked and cross-referenced with medication and any other relevant documentation relating to care needs. Records show that service users had a comprehensive plan of care including risk assessment, but the documentation in some care plans was not completed, as records show gaps in recording of daily notes, weight not checked on a regular basis, when it was identified this was required and some incident report did not have date or time, when incidents happened. Records show that service users have access to health care services including chiropodist, optician and dental services. Some service users had also been referred to specialist services including tissue viability, continence advisors and CPN services. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 10 Medication records discussed with the manager and records examined. Policies and procedures in place for staff to follow, only the manager and one senior carer has completed their accredited training, but all senior care staff have commenced on this training course. Random Mar sheets and controlled drugs checked, all of which was satisfactory on the day. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 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) 12 13 14 15 Atmosphere within the home appeared good and lots of verbal communication between staff, service users and visiting relatives, and all the standards in this area are met. EVIDENCE: The home has a hobby room, which houses resources for activities, library books and can be used for one to one work. The activities organiser was found to be very enthusiastic about her role and tries to ensure that activities are suitable for service users needs and choice. Various booklets and information for service users and families, is on the notice board in reception. Residents spoke about their preferences for communal areas, some rooms being quieter than others, and they clearly had their own personal routines and from observation during the day it was noted that some residents spent part of the day in their own rooms before joining the others, and the reception area seemed to be a popular place to sit and greet visitors to the home, who were in and out of the home from early morning. Service users also confirmed that they are encourage to exercise choice and control over all daily living needs, stating they manage their own finances, and make choices when they need too, during periods of observation it was clear residents pleased themselves in their movements around the home. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 12 A number of visitors spoken to confirm that they can visit at any time and always made welcome and they are kept informed of any issues or concerns. Service users receive an wholesome and appealing balanced diet as the home follows the Four Seasons weekly menu plan; this contains a diverse selection of choices for meals, they also ensure that there are basic stocks of food available at all times for service users who do not want the choices available on the menu. Staffs were noted to take time to present the tables attractively, to ensure that service users are in pleasant surrounding at meal times, and staffs were present throughout the meal to serve and give assistance when necessary. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 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 standard(s) 18 Vulnerable adults procedure in place ensures that service users are protected from abuse. EVIDENCE: The company has policy and procedures in place for adult protection, which was discussed with the manager, and she attended the local Adult Protection launch and although staff has done some in-house training regarding vulnerable adults and whistle blowing policy, the manager looked at what outside training was available, and some staff are attending Doncaster College on a Abuse and its Prevention course. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 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 standard(s) 22 24 26 The new bathing hoist must be fitted to ensure service users are safe when bathing and maximise their independence. And the current practice of ironing could endanger the safety of service users, has a matter of health and safety. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 15 EVIDENCE: Although the home has some hoist facilities, they were asked to review this due to the changing needs of the resident group within the home, 60 of service users within the home require bathing by using the hoist facility. This was reviewed by management and the home has purchased a further hoist facility for the downstairs bathroom, however this is still waiting to be fitted and must be addressed as soon as possible. Tour of bedrooms of random bedrooms found them to be individualised with memorabilia and many residents have brought personal items with them. Those bedrooms that were identified as requiring double sockets fitted as they have numerous electrical appliances, and were using extension leads now have two double sockets fitted, however other bedrooms continue to lack this provision. Laundry facilities are sited in the homes basement, they have one washer and one dryer and at the present domestic irons are doing all the ironing, but the manager informed the Inspector that a roller press is on order for the home. A further visit to the home and the roller press had been delivered and in the reception, the Inspector asked a member of staff why it was not in the laundry and was informed that this was going to be used by night staff in the lounge area. This current practice could endanger the safety of service users, has a matter of health and safety. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 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 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 28 Appropriate staffing and skill mix, to meet service users care needs, but certain practices could endanger the safety of service users. EVIDENCE: Staffing was discussed with the manager and rotas examined, which shows staffing levels are appropriate for care needs, but ancillary staff are not sufficient has the home do not employ laundry assistant and care staff complete this task, however this is not identified on duty rota. Most washing and ironing is completed by care staff both on day and night shifts, although most of the ironing is done at night, but this raised issues has staff complete this task in the lounge area of the home using a domestic iron and board. This practice could endanger the safety of service users if any emergency circumstances arise. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 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) 31 35 37 38 Service users live in a home that is managed to ensure their safety and protection, and so far as is reasonably practicable the health, and welfare of all service users are promoted. EVIDENCE: The registered manager is settling into her role and stated she tries to ensure that the home meets its stated purpose, aims and objectives. She continues to develop her role by completing the registered managers award. Safe working practice was discussed with the manager, observation of staff using wheelchairs with service users, and a number of records checked all of which was satisfactory and evidence seen that all maintenance checks are carried out on a regular basis and recorded. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 18 Recent issue raised regarding door guards, has some service users like their doors to remain open during the day has they spend a lot of time in their bedrooms. Some service users have paid for these items themselves, therefore the company have amended their statement of purpose to include that service users have to purchase these items. Although service uses can access any money they need, this is now pooled and kept in one account so the Inspector could not audit individual service users money. WOODLEA CS0000007982.V182775.R01.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x 3 2 x 2 x 2 STAFFING Standard No Score 27 2 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 x x x 2 x 2 2 WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 20 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. Standard OP2 Regulation 5(1)(b)(c) Requirement The Registered person must ensure that;Each service user is provided with a statement of terms and conditions/ contract at the point of moving into the home. Care plans staff must;document the date and time on incident reports,monitor service users weights and recording of daily care given to service users. Timescale for action 1st September 2005 2. OP7 15(1)(2) 1st July 2005 3. OP22 23(2)(c ) New bathing hoist must be fitted 1st July to ensure service users are safe 2005 when bathing and maximise their independence. The home needs to reassess laundry procedures, has the current practice could endanger service users health and safety. The home need to either employ laundry assistant or highlight an extra member of staff on the duty rota that is responsible for this task on each shift. 31st July 2005 4. OP26 16(2)(e) 5. OP27 18(1) 1st July 2005 WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 21 6. OP37 17(1) Records required by regulation for the protection of service users are maintained, up to date and accurate. Door guards;if these are not provided by the company this must be clearly documented in the statement of purpose and statement of terms and conditions. 1st July 2005 7. OP38 4(1)(b) 31st July 2005 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 OP24 OP28 Good Practice Recommendations Continue to ensure that service users have two accessible double sockets if requested. A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. The registered manager achieves NVQ 4 in management by 2005. Good practice; All services users money kept in the home should be kept in individual wallets 3. 4. OP31 OP35 WOODLEA CS0000007982.V182775.R01.doc Version 1.30 Page 22 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire DN4 5HZ 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. 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