Inspection on 05/01/06 for Woodleaze EMI Unit

This inspection was carried out on 5th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodleaze EMI Unit 30/04/09

Woodleaze EMI Unit 03/05/07

Woodleaze EMI Unit 24/05/06

Woodleaze EMI Unit 13/05/05

Woodleaze EMI Unit 13/10/04

Woodleaze EMI Unit 16/04/04

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

CARE HOMES FOR OLDER PEOPLE Woodleaze EMI Unit Station Road Yate South Glos BS37 4AF Lead Inspector Paul Clark Unannounced Inspection 13:00 5 January 2006 th 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 Woodleaze EMI Unit DS0000034159.V254401.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. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodleaze EMI Unit Address Station Road Yate South Glos BS37 4AF 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) 01454 866043 01454 866041 South Gloucestershire Council Mr Daniel Gerard Rooney Care Home 34 Category(ies) of Dementia - over 65 years of age (34) registration, with number of places Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th May 2005 Brief Description of the Service: Condition of registration: The home will care for people with Dementia- aged over 65 years. Woodleaze is operated by South Gloucestershire Council and the Registered Manager is Mr. Daniel Rooney. The home is registered to accommodate thirty-four older people with dementia. Two of these places are kept for short term care. Each of the 34 single bedrooms have a wash hand basin. None of the rooms have an ensuite facility. The property is arranged over two floors with shared space on the ground level and bedrooms on both floors. There is a central courtyard which is pleasantly laid out with flower and plant containers and exterior furnishings. Woodleaze is a purpose built home which was built in the 1980s. It is one of 8 care homes for older people operated by South Gloucestershire Council. Woodleaze is the only one of the 8 homes that offers specialist care for the Elderly Mentally Infirm (EMI). The home is close to shops, amenities and bus routes. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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. Woodleaze EMI Unit DS0000034159.V254401.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 Woodleaze EMI Unit DS0000034159.V254401.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): 1-6 Admissions are well planned with representatives of service users provided with good information about the home along with statements of terms and conditions. EVIDENCE: The Inspector reviewed the Statement of Purpose. The home has comprehensive information documents which give all stakeholders full information about the services provided i.e. the staff working in the home; the organisational structure; an outline of the philosophy and ethos of the home. The Registered Manager said that a Service User Guide would not be appropriate for this service user group. All service users have a diagnosis of Dementia given by a Psycho-Geriatrician and will have undergone a full assessment of their needs prior to admission. This is generally carried out by a member of the Care Management Team. There is further monitoring and review of the assessment after 4 weeks followed by further reviews carried out at appropriate frequencies. Placing Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 8 social workers, service users and their relatives attend review meetings. A random number (3) of case files were seen by the inspector, all of these had comprehensive Service Provider Plans which had been appropriately reviewed. The home operates a key worker system whose work is supervised by a member of the Care Management Team. Individualised terms and conditions of residency are made available to service users and their representatives on admission to the home. There are two places available for short-term care. Woodleaze EMI Unit DS0000034159.V254401.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): 7-11 Residents health and personal care needs are well met by a dedicated management and staff group. EVIDENCE: Care plans based on models of good practice were in place for service users and these were well constructed and clearly written. Care Plans are fronted with a photograph of the Service User to ensure that inaccuracies are avoided. The Home has put in place a Service Provider Plan format based on the principal of person centred planning. Care plans had been written based on observations of service users, and some consultation with the service users relatives. Staff had consulted with relatives about service users life before they were admitted to the Unit. Goals in the care plans were based on what the needs and wishes of the service users may be. Each care plan showed how to assist the service users with a range of physical, communication, social, mobility; and dietary needs. The care plans had been regularly reviewed and updated. There was information included that showed how to support service users who may experience confusion and agitation as a result of their dementia. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 10 The Inspector observed staff assisting service users with personal care needs in a courteous manner. Care staff were seen speaking to service users in a polite and respectful manner. Service users are registered with local GPs’ surgeries that provide support and medical back up when required. There was information in service users’ records that showed service users are referred for specialist appointments at hospitals when necessary. The district nurses provide nursing support for service users at the Home. Community Psychiatric Nurses also provide regular support to service users and the Home. The Home’s Accident Report Book was reviewed. The record of service users accidents was reviewed for the previous six months, the record showed that accidents were followed up and evaluated. Copies of accident records are forwarded to a senior manager at South Glos. Council head office. There is an induction programme in place for all staff that includes the principles of maintaining service users privacy and dignity both whilst they are living at the Home and up until the time of their death. The Inspector reviewed the Home’s procedures for the administration, ordering, storage, and disposal of medication and witnessed the administration of medication. This was seen to be done correctly and in line with the recommendations of the Pharmacy Inspector which were made at the previous inspection. Woodleaze EMI Unit DS0000034159.V254401.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): 12-15 Residents are encouraged to participate in a wide range of activities designed to stimulate and the home promotes choice and variety in all areas. EVIDENCE: A fully detailed programme of activities is in place which details forthcoming events. Discussion with staff, service users and with the relatives of service users took place on the planning and delivery of trips and activities. The ‘Activities Book’ was seen. This recorded past and forthcoming events and as well as giving a clear description of events undertaken, it also gave comment on the level of enjoyment. The Home also has an ‘in house’ newsletter, which informs the reader about recent and forthcoming trips and activities in the Home. There is a good range of social activities held in the Home for service users. Activities include flower arranging, watching videos, and going for a walk to the shops, ‘sing-along’ sessions, crafts sessions, and ‘low key’ reminiscence sessions. There was craftwork on display that service users had made and there were photographs of social events, on display involving service users. A weekly religious service is held in the Home. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 12 The inspector saw much evidence of good practice in respect of reality orientation and reminiscence work. One particular example was the presence of ‘Memory Boxes’ which staff had constructed and displayed on the walls of the Home. These provide examples and scenarios of times, events etc. which are intended to stimulate memory and interest. The Home supports the organisation of a Relative’s Support Group which meets every three months to share information and plan areas of support for service users. This meeting often takes place in a local pub or is part of a fish and chip supper for relatives. Relatives may visit the Home at any reasonable time of day and may be received in any of the communal areas of the Home or in service users rooms. The Home provides a range of nutritionally well balanced and varied meals. Service users, who cannot always verbally express their wishes in advance, are still offered a choice of meals, at the time when meals are served. Meals are well presented. The service users menu record was reviewed. Food preparation and kitchen facilities were seen by the inspector. Catering staff were interviewed. Dining was observed and service users were asked for their comments on the quality of food provided. These comments were all favourable. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 The home’s complaints procedure is widely available and known to service users representatives and staff. There are systems in place for the protection of vulnerable adults. EVIDENCE: The Home has informed service users and their relatives of their right to make complaints and of the procedure for doing so. The ‘Complaints Procedure‘ leaflets were seen to be displayed in the entrance hall of the home. The statement of terms and conditions includes the complaints procedure, and the address of the Commission. Relatives of service users spoken to during the Inspection stated that they were aware of the Home’s Complaints Procedures. The complaints logbook record book was reviewed. There had been two complaints received since the last inspection which had been responded to appropriately. The Home has introduced a ‘comments’ book, kept in the entrance hall, for relatives, and service users to comment if they wish about the service .The Home is to be commended for taking an ‘open’ approach, and for actively seeking feedback about the service. The Home has a ‘protection of vulnerable adults from abuse’ policy. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 14 This was kept readily accessible for staff. The Home has produced a ‘Guidelines for Staff on POVA’. The ‘Guidelines for Staff on POVA’ document was seen. Staff training records showed that newly appointed staff have attended training sessions on the Protection of Vulnerable Adults as part of their induction programme. The Home also has a ‘whistle blowing’ policy, which details actions staff would be required to follow. Staff were interviewed and asked about their awareness of the POVA and Complaints Procedures. In discussion with the Inspector staff demonstrated an awareness of some of the issues around the protection of vulnerable adults from abuse. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 15 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): 19-26 The environment is homely and stimulating and although generally well maintained there are some areas that need improvement. EVIDENCE: The Inspector conducted a visual inspection of all areas of the Home including bedrooms and exterior areas. Staff were interviewed and residents and their visiting relatives opinions were sought about the physical standards in the Home. All parts of the building were clean, tidy and with pleasant furnishings and décor. Domestic staff were observed cleaning the Home. At the time of the Inspection some parts of the building were oppressively hot, the Inspector brought this to the attention of management and staff. It was stated that there have been ongoing difficulties with the regulation of the heating system. It is required that the regulation of the heating system be attended to. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 16 Dementia Voice advised the Home on the décor, and advised strong primary colours were to be used as a means of communication. Corridors and toilet doors are painted in bold primary colours. The seating in the communal lounges was pastel coloured. There were windows in each room giving plenty of natural light. There were light coloured carpets with prints and pictures displayed, which helped to create a homely look. There were groups of service users sitting in the living rooms, drinking cups of tea, watching television and walking along the corridors. The communal dining room was spacious in size. Bedrooms were clean and tidy, and many rooms had small personal items and pieces of furniture in them. Rooms were above the minimum spatial requirements in the National Minimum Standards. There was a window in every bedroom that gave each room plenty of natural light and ventilation. However, many of the window frames are now quite old and several require attention. It is recommended that the quality of the window frames throughout the home be reviewed and that those of poor quality should be replaced or renovated. Rooms had linoleum flooring, and there were curtains at each bedroom window. There was a wardrobe and a chest of drawers in each bedroom. Although none of the rooms had en-suite facilities there were toilets and bathroom facilities located close to communal living rooms. There were signs prominently displayed outside the toilets and bathrooms. The toilets and bathrooms were clean and tidy when viewed. The Home has a policy aiming to address ‘infection control. There was soap, and a supply of paper hand towels at the hand washbasins, next to the toilets. There is an internal courtyard accessible to service users where there is seating, planted tubs and a water feature. As this is an area which service users enjoy and visit frequently the uneven, concrete surface represents a potential danger. It is recommended that the courtyard surface area be covered with a soft exterior surface material to protect service users who may fall. The Inspector expressed concern about the entry arrangements around the entrance porch which make wheelchair access difficult. It is recommended that this arrangement be reviewed. There is off street parking provided, and the Home is accessible for wheelchair users. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 17 Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 18 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): 27-30 Service users are safely supported by a staff team that are well supervised and generally well trained. However, 50 of care staff should be NVQ Level 2 qualified. EVIDENCE: There are a sufficient number of care staff on duty by day and by night to ensure that the needs of service users are met. The number of domestic, laundry and catering staff ensures that care staff are not diverted from the caring role. There is 25 hours per week administrative support. Bank staff are used to cover staff illness and holidays. Staff personnel and training records were reviewed. Sound staff vetting and recruitment practices are in place. New appointments do not start work until 2 references, a health clearance and satisfactory Criminal Records Bureau, and ‘POVA’ checks are complete. The authority’s Induction Programme for new staff was viewed. The induction programme ensures that all care staff receive training in First Aid, Food Hygiene, Fire Safety, Manual Handling, Dementia Awareness, Continence Management and ‘Protection of Vulnerable Adult’ training to be included in the induction programme). 2 staff have a National Vocational Qualification (NVQ) at Level 2 in Care. 1 staff has a NVQ Level 2 qualification. 9 staff are registered as NVQ Level 2 Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 19 Candidates. It is recommended that at least 50 of care staff are qualified to NVQ Level 2. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 20 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): 31-38 The home is well managed in all areas supporting staff and service users within a safe environment. EVIDENCE: The Registered Manager is due to complete NVQ Level 4 within the next 12 months and this will be a focus of the next Inspection. Staff supervision records were seen. All care staff receive supervision approximately every 4-6 weeks. Team Meeting minutes were viewed. Team meetings are held approximately every 4-6 weeks. An appropriate system is in place for handling service users finances. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 21 The environment looked to be maintained to a satisfactory standard in all areas that were viewed. The staff training records showed staff attend relevant health and safety update training. Service users accidents and ‘incidents of concern’ are recorded, and this information is audited. Copies of these records are sent to a senior health and safety manager at South Glos. Council. The temperatures for the kitchen fridge and freezers were being checked on a daily basis, and the record was up to date. Food being served was being temperature checked prior to serving. The fire logbook record showed weekly and monthly tests and inspections of the fire alarms and the fire fighting equipment were being carried out and these tests were up to date. Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 22 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 19 Regulation 23 Requirement It is required that the regulation of the heating system be attended to. Timescale for action 01/03/06 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 19 25 Good Practice Recommendations It is recommended that the quality of the window frames throughout the home be reviewed and that those of poor quality should be replaced or renovated. It is recommended that the courtyard surface area be covered with a soft exterior surface material to protect service users who may fall. The Inspector expressed concern about the entry arrangements around the entrance porch which make wheelchair access difficult. It is recommended that this arrangement be reviewed. At least 50 of Care staff should qualified to NVQ Level 2 in Care 3 19 4 30 Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Woodleaze EMI Unit DS0000034159.V254401.R01.S.doc Version 5.0 Page 25 - 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. 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