CARE HOME ADULTS 18-65
Woodlea Residential Care Home Woodlea 196 Upper Chorlton Road Manchester M16 7SF Lead Inspector
Val Bell Unannounced Inspection 31st May 2006 10:00 Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 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 Residential Care Home DS0000005637.V299722.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 Adults 18-65. 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 Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Woodlea Residential Care Home Address Woodlea 196 Upper Chorlton Road Manchester M16 7SF 0161 862 9521 0161 882 0744 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) Mr S Pascau Mrs Dorothy Heaton Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. All the service users will fall within the category of mental disorder and may also have an associated learning disability (Two named service users currently accommodated are aged 65 years or over). 16th December 2005 Date of last inspection Brief Description of the Service: Woodlea is a private home providing 24-hour care for up to 15 adults with enduring mental ill health. Some of the residents may also have a physical disability. The home is a large converted Edwardian House set in a residential area of Trafford. Shops and a post office are within walking distance from the home. Public transport routes into Manchester city centre and the surrounding area are close by. The philosophy of the home is to maximise the potential of each resident and to develop and maintain independence. Accommodation is provided in 15 single bedrooms, none of which have en-suite facilities. Sufficient toilet and bathroom facilities were provided to meet the needs of the residents. Communal space comprised of a lounge with connecting dining room and a non-smoking lounge on the lower ground floor. There is a large private garden to the rear of the property and parking space at the front. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was included a site visit by two inspectors over two days, 31st May and 1st June 2006. During the site visits conversations were held with residents and staff and management on duty in addition to a visiting employee from the local pharmacy. A selection of records was examined including care plans, personnel files and health and safety records. The inspectors also undertook a tour of the home. One of the two requirements made at the last inspection in December 2005 had been addressed. What the service does well: What has improved since the last inspection? What they could do better:
Further development was needed in the area of risk assessment to ensure that residents who used kettles in their bedrooms could do so safely. A safe system of medication administration was in place although two minor shortfalls
Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 6 relating to the recording of medication were noted. It was recommended that a person-centred planning model be adopted, as this would promote autonomy and self-determination for individual residents. In relation to staffing, a requirement was made to bring the induction of staff in line with the specifications of the ‘Skills for Care’ organisation and it was recommended that personnel files were reorganised to make the finding of information easier. Several areas of serious concern were present in the storage of food and the cleaning of food preparation areas. This potentially placed the health and welfare of residents at risk. Additionally, the home must implement new food safety legislation that came into force on 1st January 2006. Furthermore, two good practice recommendations were made to promote resident choice at mealtimes and to ensure that their dietary needs were being met. Quality assurance surveys were overdue. These must be offered to residents and visitors to the home on an annual basis. Effective health and safety monitoring was in place at the home although the recording of monthly fire alarm checks had not been done consistently. Lastly, the requirement made at the previous inspection to remove the advertising board at the front of the home had not been addressed. However, the provider said that this would be removed in the near future. 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 Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents could be confident that their individual needs would be identified following admission to the home and that any changes in their needs would be updated. EVIDENCE: Three care plans were examined during the site visit. Comprehensive in-house assessments of need had been undertaken and multi-disciplinary assessments of need had been obtained from the local authority. This meant that the individual needs of each resident could be identified and formulated into a care plan. The home adopted a policy of reviewing needs on a monthly basis. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A robust system of care planning ensures that the assessed needs of residents will be met. EVIDENCE: Care plans were up to date, detailed and contained relevant information. This was particularly evident in the care plan of a recently admitted resident. This had been structured to guide care staff on responding appropriately to certain behaviours that had been identified in the resident’s assessment of need. This was considered to be a model of good practice and a recommendation was made for this to be used in similar situations for other residents. The quality of risk assessments contained in the care plans was generally good. It was noted that some residents used kettles in their bedrooms and this had been assessed from an environmental point of view e.g. to identify potential hazards such as trailing wires. However, it is required that individual residents are risk assessed to ensure that they are able to use a kettle safely.
Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 10 From conversations with residents it was evident that people living in the home were encouraged to make decisions concerning issues that affected their daily lives, such as daily routines and participation in household tasks and community activities. The homes notice board displayed information about the opportunities available to residents and an information folder was available. Additionally, the people living in the home were regularly consulted on a daily basis and more formally at residents meetings where group decisions were taken. Care plans needed some development to record evidence that the home promoted residents individuality in decision-making. One way in which this can be achieved is by adopting a person-centred planning approach. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 and 17 Quality in this outcome area is poor in relation to the health and safety of residents. This judgement has been made using available evidence including a visit to the service. Residents had access to activities that provided stimulation and interest. Shortfalls in the storage, preparation and provision of food potentially placed the health and safety of residents at risk. EVIDENCE: Residents were provided with information on educational courses and supported employment opportunities available in the local community and leisure activities were provided in the home. Some of the residents said that they enjoyed shopping, discos, swimming and the occasional visit to the local pub. Residents and staff confirmed that the people living in the home kept in touch with their family and friends. Resident’s rights were respected and they were encouraged to take responsibility for keeping their private space clean and tidy
Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 12 and to participate in general household tasks. People living in the home had access to all parts of the environment and routines were generally flexible. The kitchen and food stores were assessed on the first day of inspection and several shortfalls were found to be present as follows: • Food stocks were very low. There was no butter or bread in the home and a different meal to the one on the menu had to be prepared. A member of staff told the inspectors that this had happened several times. The manager said that negotiations were underway with a new food supplier and that this situation would improve. The handle on the fridge was broken An open packet of frozen vegetables had not been re-sealed and a packet of frozen meat was not labelled Sandwich ham in the fridge had passed it’s use-by date Cartons of drinks, potatoes and a chopping board were being stored on the floor The deep-fat fryer drain was blocked and contained stagnant water The floor area around the cooker needed to be cleaned as there was a build up of crumbs and food debris Although an electric fly killer had been installed in the kitchen the environmental health inspection on 7/7/05 had identified that a fly screen should be fitted to the window. The home had not implemented new food safety legislation as required from January 2006 • • • • • • • • Furthermore, menus did not offer residents a choice at mealtimes and it appeared that group decisions were taken regarding meals, such as whether to have fish on a Friday. The home should develop a system of meal planning that reflects the preferences of individual residents wherever possible. A further recommendation was made to keep a list of the dietary needs of individual residents in the kitchen for ease of reference. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents could be confident that their assessed personal and healthcare needs would be met. EVIDENCE: Residents confirmed that their preferences regarding the way in which their personal care was provided were respected. Care plans provided evidence that the health care needs of residents were being met by making the appropriate referrals to health care professionals. It was pleasing to note that residents had been encouraged to attend regular dental check-ups. One resident told the inspector that she had not been to a dentist for some considerable time but with staff support she had developed the confidence to have regular dental treatment. The home had maintained a safe system of medication administration. Two minor shortfalls were noted. The morning medication for one of the residents had been signed for as given, although the tablets were still in the blister pack. Additionally, the use of ‘O’ in the administration records is not adequate in explaining why medication has been omitted. A full explanation must be recorded.
Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 14 The inspector had a conversation with a representative from the local pharmacy who was visiting the home during the inspection. He confirmed that medication returned to the pharmacy was accurately recorded and signed for. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Robust systems for addressing complaints and dealing with allegations of abuse offered protection to resident’s welfare. EVIDENCE: The anonymous complaint made to the Commission prior to the last inspection was outstanding. This referred to the advertising board at the front of the home. The owner confirmed that the board would be removed. Residents said that they knew whom to approach if they had any concerns or complaints and they were confident that any concerns would be resolved to their satisfaction. The home had adopted local authority procedures for the protection of vulnerable adults from abuse and the inspectors were told that training for staff in abuse awareness would be provided. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were provided with a clean and safe living environment. EVIDENCE: The home employed a housekeeper to oversee cleaning in the home. On a tour of the premises the home was found to be generally clean, safe and no offensive odours were present. Lighting, heating and ventilation appeared to meet resident’s needs. As previously mentioned earlier in this report, shortfalls in the kitchen environment were a cause for concern. Public transport links and community amenities were accessible to residents. The homes development and maintenance programme was ongoing. Staff on duty, were asked what they thought of the environment. Comments included ‘it’s ok’ and ‘could be better’. It was noted that some of the armchairs in the lounge were not domestic in nature, but more suited to the needs of older people and all the chairs had been positioned around the walls. A good practice recommendation was made to consult residents on how the environment could be improved to give it a more homely feel.
Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 17 One of the residents showed the inspectors his bedroom and said that he was happy with the facilities provided. Another resident told the inspector that he had recently undergone a hip replacement. He added that he had been offered a ground floor bedroom and that he had found this beneficial to his recovery. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Robust recruitment procedures offer protection to the safety and welfare of people living in the home. EVIDENCE: In conversation with the inspectors staff on duty were able to demonstrate their understanding of the assessed needs of residents. They appeared to have developed good relationships with residents and were approachable and responsive to requests for information. Four staff hade achieved NVQ level 2 in care and a further four were working towards this qualification. The homes rota’s provided evidence that staff are deployed in excess of the minimum numbers required. It was pleasing to note that the home had joined Trafford Training Consortium, which will provide the relevant training opportunities for staff development. Four personnel files were examined to assess the homes method of recruitment and selection and training of staff. Essential pre-employment checks had been obtained prior to appointing staff in post. Copies of training certificates and induction schedules were held. It was required that the induction of staff be brought into line with the recommendations of ‘Skills for
Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 19 Care’. The manager stated that further training was planned in health and safety, behaviours that challenge services and dual disability. More care must be taken in ensuring that application forms are completed in full, as one of those assessed was incomplete. A further recommendation for improvement was made to organise the personnel files so that information could be more easily located. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. A robust system of health and safety monitoring offered protection to the resident’s welfare. EVIDENCE: The manager has achieved NVQ 4 in care and management and has a certificate in business management. Quality surveys with visitors to the home were last undertaken in January 2005 and there was no evidence that this process had been undertaken with residents. The homes quality assurance system must be developed and brought up to date. The requirement made at the previous inspection to display both parts of the certificate of registration had been met. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 21 The homes health and safety records were examined and found to be generally up to date. A shortfall was noted in the fire alarm test records. The manager said that she had tested the fire alarm on a monthly basis although this had not always been recorded. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X 3 2 X Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 23 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 YA9 Regulation 13 (4) Requirement Risk assessments must be carried out for those residents that use kettles in their rooms to ensure that they can use the equipment safely. The registered person must provide at all times adequate quantities of suitable and wholesome food as may be required by residents. The registered person must keep accurate records of the food provided to residents. The registered person must ensure that food is stored according to the requirements of food safety legislation. The registered person must provide written evidence that the cleanliness of the kitchen and food storage/preparation areas is being monitored on a daily basis. The registered person must comply with the requirements of The Food Hygiene (England) Regulations 2006, in implementing a documented food safety management system.
DS0000005637.V299722.R01.S.doc Timescale for action 01/07/06 2. YA17 16 (2)(i) 01/07/06 3. 4. YA17 YA17 17 (2) 13 (4)(c) 01/07/06 01/07/06 5. YA17 23 (2)(d) 01/07/06 6. YA17 23 (5) 01/08/06 Woodlea Residential Care Home Version 5.2 Page 24 7. YA17 13 (4) 8. YA22 12 (4) The registered person must fit a suitable fly screen to the kitchen window to minimise the risk of food contamination from flying insects. The registered person must remove the advertising board at the front of the home. 01/09/06 01/07/06 9. YA35 18 10. YA39 11. YA42 The registered person must 01/08/06 review and update the induction programme for new staff to include the areas specified by the ‘Skills for Care’ organisation. 24 The registered person must 01/09/06 implement an annual programme of quality assurance that seeks the views of residents and visitors to the home. 23(4)(c)(v) The registered person must 01/07/06 ensure that the monthly testing of the fire alarm is recorded. 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 YA6 Good Practice Recommendations The registered person should consider using the good practice model of recording specific behaviours in place for one of the residents to ensure that staff know how to respond to behaviours that challenge delivery of the service. The registered person should adopt a person-centredplanning model to ensure that resident’s individuality is maximised. The registered person should ensure that residents are offered choices at mealtimes. A list of residents specific dietary needs should be available to staff preparing meals in the kitchen. The registered person should implement a monitoring system to ensure that medication records are completed accurately.
DS0000005637.V299722.R01.S.doc Version 5.2 Page 25 2. 3. 4. 5. YA8 YA17 YA17 YA20 Woodlea Residential Care Home 6. 7. 8. YA20 YA24 YA34 The registered person should ensure that the reason for an omission of medication is recorded. The registered person should consult residents on how the main lounge can be reorganised to give it a more homely feel. The registered person should ensure that application forms are fully completed. Additionally, personnel files would benefit from restructuring to make information easier to locate. Woodlea Residential Care Home DS0000005637.V299722.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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