Inspection on 03/11/05 for Woodlea

This inspection was carried out on 3rd November 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 26/05/05

Woodlea 07/01/05

Woodlea 21/07/04

Woodlea 26/02/04

Similar services:

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Snydale Care Home

Hawkhills

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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 Lead Inspector Janet McBride Unannounced Inspection 3rd November 2005 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 Woodlea DS0000007982.V258704.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. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlea Address 61 Bawtry Road Bessacarr Doncaster 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) 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 DS0000007982.V258704.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th May 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, 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. 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, Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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 Care Home, on the 3rd November 2005, commencing at 09:30 and finished at 15:30,this was the homes second Inspection since April 2005. Any standards not covered in this inspection were covered in the unannounced inspection that was conducted early in the year. It may be the case that some standards will be covered twice in the inspection year 2005/2006, which is considered good practice, and consistent with a professional approach to regulation. During the Inspection we looked at chosen number of documents, sampling of records, and direct and indirect observation of staff interaction with residents, this Inspection also included individual and group discussions with residents, and feedback from relatives and visitors on the day. What the service does well: What has improved since the last inspection? All residents have been issued with a contract/statement of purpose and are aware of services and facilities that the home provides. New equipment for the kitchen, corridors decorated, and security camera fitted to the building outside, to provide extra security for the home. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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 Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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): 26 Current residents in the home are provided with a contract of the terms and conditions, which ensures that residents are aware of services and facilities are provided by the home. EVIDENCE: The company have recently sent all current residents contracts/statement of terms and conditions; this includes private clients and those residents funded by social services. One of each of these contracts were examined and found they contained the relevant information required by this standard. All residents within the home receive personal care and accommodation, but the home does not provide intermediate care Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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 Each resident receives health and personal care based on their individual needs, to ensure that their needs are fully met and they are referred to any specialist services when required. EVIDENCE: Care plans were case tracked on the last Inspection; therefore only two care plans were checked on this occasion. These care plans were cross-referenced with medication, accident and incident reports. Records show that residents had a comprehensive plan of care including risk assessment, nutritional assessments and evidence was seen that residents are referred to social services for re-assessment due to changes in care needs. Some issues were raised about documentation; gaps in recording of daily notes and some plans of care requiring updating. Records show that residents have access to health care services including a registered GP, chiropodist, optician and dental services. Some residents had Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 Page 10 also been referred to specialist services including tissue viability, continence advisors and CPN services. Medication records discussed with the manager, and records show that no recent audits have been carried out either by the manager or visiting pharmacist; therefore records were examined again on this Inspection. Policies and procedures in place for staff to follow, staff that administer medication have completed an accredited medication training, which was confirmed when speaking to staff. Random Mar sheets, stocks of medication and controlled drugs were checked, with some issues being raised; Mar sheets that were hand written were not signed by two members of staff, stocks of medication show that, stock is not rotated, out of date medication, large quantities of medication being stored and residents not having medication reviewed by there GP. All these issues were discussed with the manager at the time. Staff was observed delivering care to residents, they were seen to approach residents with respect, knocked on doors before entering and encouraged independence. Personal care took place in private and, any visiting health professionals were shown to residents’ individual bedrooms or a bathroom they use as a treatment room. Staff seen stated the importance of maintaining communication with families and was aware of treating residents with respect, dignity and privacy at all times. Relatives and resident spoken to and the comments received stated; they were happy with the care the home provide and feel its well run and that the staff are caring, clearly some residents were very self caring had their own personal routines and moved about the home without reference to staff. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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): None of these standards were assessed this time, but they were all assessed at the previous inspection and met. EVIDENCE: Woodlea DS0000007982.V258704.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 Vulnerable adults procedure ensures that residents are protected from abuse, and residents and relatives are provided with information to enable them to raise concerns or complaints about the home and their care. EVIDENCE: Complaint and protection was discussed with the manager, who is aware of her responsibilities, and records show, the home use the Four Seasons complaints procedure, which is displayed in the reception area and gives clear indications of the timescales a complainant can expect. No complaints have been recorded since the last Inspection, and residents and relatives seen were aware of the homes complaint procedure and would use it if necessary. Woodlea DS0000007982.V258704.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 26 Residents live in a safe and well-maintained environment; this ensures that residents have comfortable surroundings, with their own possessions around them. EVIDENCE: Location and layout of the home is suitable for its stated purpose, the home is registered for 34 beds, but the percentage of single rooms within the home is less than 80 as the home currently has four double rooms; three of the shared rooms are undersize. This was discussed with the manager and advised that when bedrooms are shared evidence must be seen that residents are consulted and have made positive choice to share with each other, and if shared place become vacant, the remaining resident has the opportunity to choose not to share, and evidence must be seen that the management have given residents this choice, at the time of Inspection they had 4 empty beds and 3 of these were single rooms. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 Page 14 Partial tour of the home found it to be clean and tidy, communal corridors have recently been re-decorated and new chairs have been purchased for one of the lounges. Toilet, washing and bathing facilities are sufficient to meet residents needs, but issues were raised during the tour of the premises. One bathroom was identified as needing refurbishing, as ceiling tiles were missing or cracked. Another bathroom that is also used as a treatment room by visiting district nurses, if this continues to be used in this way; the home must arrange for storage of dressing and creams and personal files to be kept in a secure cabinet, and not use this room as a general stock room for any other items. There is a variety of mobility aids in use at the home, which have been provided following individual assessment by specialist therapist. Residents access the upper floor via a passenger lift, and ramps are provided to the garden areas, handrails, aids and hoists are provided. Laundry facilities are sited in the homes basement, they have one washer and one dryer and since the last Inspection a roller press was ordered for the home, which as changed the practice of ironing duties within the home, to ensure health and safety of residents and staff. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 Page 15 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 Staff has the skills and knowledge to fulfil their roles within the home, and a stable staff group ensures continuity of care by staff that knows the residents. Recruitment policies are followed ensuring the safety and protection of residents within the home. EVIDENCE: Staffing was discussed with the manager, who is totally supernummary, although she may be looking at changing some of the shift patterns, as she feels this would be more beneficial to both residents and staff. Her deputy as moved to another home within the company re promotion, and she is interviewing next week for a replacement. Duty rota shows staffing levels are appropriate for residents care needs, duty rota also shows identifies staff responsible for; laundry duties, admin support, activities organiser and domestic duties. Recruitment was discussed with the manager and files examined, new staff files were inspected, these records show that the home operates a through recruitment procedure based on equal opportunities and ensuring the protection of residents. All staff has copies of their terms and conditions of employment, and a copy of the General Social Care Council code of practice. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 Page 16 Training matrix was seen, this show what training staff has completed, and staff files seen provided the evidence that this had been completed. Foundation training package for new staff; the Inspector was informed that the company trainer has verified the package and that it meets the TOPSS specifications. One new member of staff has recently worked through this package and file was available to examine. NVQ training was discussed with the manager and remains the same as the last Inspection, out of the twenty care staff; only four members of staff have completed their N.V.Q level 2. The home has a long way to go to achieve the 50 target for 31st December2005. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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 33 35 37 38 The manager and her staff try to ensure that residents living in the home are safeguarded by the homes policies and procedures to ensure their welfare; health and safety are protected and promoted at all times. EVIDENCE: Discussed with the registered manager about her role and how she runs the home. She’s aware of her responsibilities and accountability as a manager, and stated she tries to run the home for the best interests of the residents. But when discussing quality monitoring systems no evidence was found that the home or company seek the views of residents, relatives and stakeholders on a formal basis, the manager ensures she speaks to residents in the home, and tries to see any visitors and asks there views but none of this is documented, and the last residents meeting was in April this year. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 Page 18 Safe working practice was discussed with the manager; staff that were interviewed and a number of records were checked. The homes handyman completes maintenance checks on a weekly or monthly basis dependent on the task, all of which was satisfactory and evidence seen that these are recorded. Fire safety was checked and found that staff had completed fire awareness training, but no evidence was found that fire drills had been completed, however the manager states these had been carried out advised that these must be recorded to provide evidence. Staff had completed other safe working practice training throughout the year, e.g moving and handling, first aid, health and safety and infection control. Although residents can access any money they need, this is now pooled and kept in one account so the Inspector could not audit individual residents money. Records required by regulation are maintained; a number of these were checked during the Inspection and found to be accurate and up to date with the exception of some care plans, some medication records and fire records. Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X 3 X 2 3 2 X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X 2 2 Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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 OP7 Regulation 15(1)(2) Requirement Care plans; The registered manager must ensure that care plans are updated re risk assessments. Timescale for action 01/12/05 2 OP9 13 3 OP21 23(2)(b) 4 OP21 23(2)(b) Medication; The registered 01/12/05 manager must ensure that staff follow policies and procedures with regard to; 1) MAR sheets that are hand written must have two signatures. 2) Medication stocks; must be not over stocked, rotated and dates checked. 3) Resident’s medication must be reviewed by the GP on a regular basis. Bathrooms, 1st bathroom 01/01/06 requires refurbishing re missing or cracked ceiling tiles, and scuffed paintwork and walls. Bathroom, 01/12/05 2nd bathroom is being used as store room/treatment room the company must address this area and make suitable arrangements for the storages of service users nursing files and dressings. DS0000007982.V258704.R01.S.doc Version 5.0 Page 21 Woodlea 5 OP33 24(1) Ensure that Quality systems are 01/01/06 in place to measure success in meeting the aims, objectives and the statement of purpose of the home. Audit of the home and seek the views from service users, familys and stakeholders. The registered manager must ensure that Records required by regulation for the protection of service users are maintained, up to date and accurate with regard to; Care plans, medication records and fire records. Fire safety, A record must be kept of fire practice/ drills conducted within the home. 01/12/05 6 OP37 17(1) 7 OP38 17(2) Schedule4 01/12/05 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 Assess the use of shared rooms, and provide evidence that these service users have made a positive choice to share with each other. 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 DS0000007982.V258704.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster 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. Extracts may not be used or reproduced without the express permission of CSCI Woodlea DS0000007982.V258704.R01.S.doc Version 5.0 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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