Inspection on 16/08/05 for Woodleigh

This inspection was carried out on 16th August 2005.

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

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

Other inspections for this house

Woodleigh 06/06/07

Woodleigh 16/12/05

Woodleigh 14/01/05

Woodleigh 13/07/04

Woodleigh 06/03/04

Similar services:

Chirnside House

Sunny Bank (P.R.S.) Ltd

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Woodleigh Callands Road Callands Warrington Cheshire, WA5 9RJ Lead Inspector Wendy Smith Announced Inspection 16th August 2005 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. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodleigh Address Callands Road Callands Warrington Cheshire WA5 9RJ 01925-235237 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) Warrington Borough Council Marine Hall Care Home 39 Category(ies) of OP - Old Age (39) registration, with number PD(E) - Physical Disabilities - over 65 (4) of places MD(E) - Mental Disorder - over 65 (15) PD - Physical Disability (4) DE(E) - Dementia - over 65 (12) DE - Dementia (12) MD - Mental Disorder (15) Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home is registered for a maximum of 39 service users including:* Up to 39 service users in the category of OP (Old age, not falling within any other category) * Up to 12 service users in the category of DE (Dementia under the age of 65 years) * Up to 12 service users in the category of DE(E) (Dementia over 65 years) * Up to 15 service users in the category of MD (Mental disorder under 65 the age of 65 years) * Up to 15 service users in the category of MD(E) (Mental disorder over 65 years) * Up to 4 service users in the category of PD (Physical disability under the age of 65 years) 2 The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Date of last inspection 14 January 2005 Brief Description of the Service: Woodleigh is a community support centre for older people which is owned and managed by Warrington Borough Council. It is a single storey modern building located in the Callands area of Warrington and is close to local shops and amenities. The home has 39 places for older people requiring personal care and there is a 25 place day centre in the same building. The home also has close links with the local authority’s homecare service. There are 23 long term places, 14 short stay places for emergency admissions and respite stays, and two places for transitional care. All service users have single bedrooms, 18 of which have en-suite facilities. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out on 16th August 2005 over a period of four and a half hours. 23 long stay residents were living at the home and a further 16 people were receiving short term care. A tour of the building was conducted, including all communal areas and some bedrooms. Time was spent in conversation with the service manager and other staff. Seven service users were spoken with. A sample of records was inspected. Some of the information contained in this report was taken from the pre-inspection questionnaire that had been completed by the manager. Comments cards were not received from any relatives or other visitors prior to the inspection, but eight residents had completed comments cards with assistance from staff. These contained mostly positive comments including two short stay residents who said how much they enjoyed their stay at Woodleigh. A comments card received after the inspection read ‘My relative could not have better care’. What the service does well: What has improved since the last inspection? Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 6 A very pleasant new garden area with seating has been developed. The smoking area has been re-sited so that it does not impact on service users who do not smoke. 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. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 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 Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 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) 3 and 4. Service users are assessed in full before admission to Woodleigh to ensure that their needs can be met. EVIDENCE: Prospective residents and short stay service users are assessed by their allocated social worker prior to admission being agreed. The home receives a completed pre-admission assessment form for all new referrals which contains comprehensive information about the person and identifies the person’s needs. If there is any doubt whether the placement would be appropriate the service manager goes out to visit the person and carries out a further assessment. The home does not admit any individuals who are prone to wandering, who require PRN medication or who have challenging behaviour, as their needs could not be met at Woodleigh. Many of the service users admitted to Woodleigh are already known to the service through the Day Centre and the Care at Home service. Most of the respite service users have regular planned stays at the home. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 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, 8 and 10 Each service user has a care plan that details their daily needs. Service users health needs are met in full. Privacy and dignity are respected. EVIDENCE: Senior care staff draw up a care plan for each service user and this takes the form of a daily routine and the help required from staff. Care staff record the care given each day and report any changes. The manager and one of the senior care staff said that the care plans are kept under continual review, however there is no indication that care plans are fully reviewed on a regular basis. There was also no evidence of goals being set and evaluations to monitor whether the care provided was achieving the goals. See recommendation. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 10 The home deals with six different GP surgeries. An identified GP practice provides medical services for service users admitted for a short stay who are outside the area covered by their own doctor. District nurses and community psychiatric nurses provide support for any service users requiring nursing input and they obtain pressure relieving equipment for service users identified as being at risk. The home also works closely with Hollins Park hospital. Service users have access to all primary healthcare facilities in the community. A chiropodist visits six weekly and will treat any service users who require a service. All except one of the service users who completed a comments card considered that their privacy was always upheld. There are locks on all bedroom and bathroom doors. One resident spoken with said ‘you can’t wish for a better place than this’. At all times staff spoke politely and respectfully to service users. Each of the living areas has a kitchenette and service users can have a hot or cold drink and a snack at any time they wish. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 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 and 13. The social and emotional needs of service users are recognised and provided for. The home welcomes visitors and is integrated into the local community. EVIDENCE: On the weekend before the inspection the home had held a ‘street party’ to celebrate the anniversary of the end of World War 2. Staff and their families had put a lot of unpaid work into organising this event. Residents from local housing schemes were invited. All of the service users spoken with said how much they had enjoyed the day. The home is without an activities worker at present and is recruiting for this vacancy. There is an activities worker in the Day Centre who also has some input in the home. Arts and crafts, reminiscence, chair based exercises and other activities are facilitated by care staff. A carer spoken with arranges regular trips out. She was planning a theatre trip in the near future. Residents also go out with their relatives and may go out to local shops. Two service users attend a local blind society. Holy communion is provided every Monday. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 12 There is a choice of sitting places in the lounges and in the ‘mall’ area and service users may join in some of the activities going on in the Day Centre. A smoking area for service users is provided at the end of the mall. Relatives and friends can visit at any reasonable time. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 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) 16 Complaints are dealt with appropriately. EVIDENCE: The home follows the Warrington Borough Council complaints procedure, which meets this standard. A copy of the complaints procedure is contained in the information pack that is given to service users. Two complaints had been recorded since the last inspection and had been investigated by an officer of the local authority. Records were provided for inspection but these did not include the action that had been taken by the manager to address one of the complaints. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 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) 19 and 26. The interior of the home is clean and well maintained but exterior woodwork needs to be repainted. EVIDENCE: Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 15 The home has five living areas each of which contains a lounge/dining room with a fitted kitchenette, bedrooms, bathroom and toilets. The ‘Mall’ area provides communal sitting space through the centre of the building and service users who smoke may do so in a part of this area. All corridors are well lit and furniture and furnishings seen were comfortable and of good quality. A very pleasant new garden with seating has been developed at the front of the building. The woodwork on the outside of the building looks shabby and needs re-painting. See recommendation. At this time the home was without a maintenance person and recruitment was taking place. In the meantime maintenance services were being provided by another local authority employee and gardens were maintained by contract. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 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 and 28. The local authority provides staff in sufficient numbers to meet the needs of service users. More staff need to achieve NVQ qualification. New staff have comprehensive induction training. EVIDENCE: The home employs 42 care staff, and 23 ancillary staff. During the day there is a senior carer and five care staff on duty, with general assistants providing housekeeping services. At night there are three care staff on duty. All of the staff spoken with were friendly and helpful and their commitment to the home was evident. A quite new care assistant said how much she enjoyed working at the home and told the inspector ‘it’s a lovely job’. 13 staff have achieved an NVQ qualification, however the Department of Health target is for a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) to be achieved by 2005. See recommendation. New staff have a two week induction with the local authority, which covers all aspects of their work. Information provided by the manager showed that inductions are held regularly throughout the year. A carer confirmed that she had attended this induction and found it very useful. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 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, 36 and 38. The home is well managed by a professional person. A system of staff supervision is in place. Some staff had not received health and safety training updates and the home’s electrical wiring certificate had recently expired. EVIDENCE: The service manager is an experienced social worker who holds a BA in professional social work and a practice teaching award. The manager is registered with the Commission for Social Care Inspection. She is working towards NVQ level 4 in management. A community services coordinator manages the administration and ancillary staff and takes the lead for health and safety matters. This person had taken up post a few weeks prior to this inspection. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 18 A system of staff supervision is in place. A senior care staff meeting is held monthly and senior care staff supervise the care assistants. New staff receive training regarding all health and safety matters as part of their induction. Training records were available for inspection and these indicated that not all staff had attended Fire Awareness training for some years and a significant number had not attended any recent health and safety training. Four of the general assistants did not have any COSHH training recorded, and a number of staff had not had a recent moving and handling refresher. See recommendation. A satisfactory report was received from the Environmental Health Officer following an inspection in April 2005. The fire alarm system is tested weekly and staff are required to respond to this. The Fire Officer visited in December 2004 and recommended that intumescent strips should be fitted to fire doors and that automatic closers should be fitted to bedroom doors. See recommendation. The electrical wiring certificate expired in July 2005 and the central heating system was due to be serviced in July 2005. See recommendation. A specialist company inspects and tests all of the home’s water systems monthly. Moving and handling equipment had been checked and serviced in July 2005. Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 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 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x 3 x 2 Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 20 No 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care plans should set aims or goals by which the effectiveness of the care being delivered can be measured and there should be evidence to show that care plans are reviewed on a regular basis. Exterior woodwork should be re-painted. More care staff need to achieve NVQ qualification in order for the home to meet the Department of Health target. The Local Authority should consider acting on recommendations made by the Fire Officer in December 2004. Staff should receive regular updates and refresher training for all health and safety topics relevant to their work. The electrical wiring should be inspected without delay. 2. 3. 4. 5. 6. OP19 OP28 OP38 OP38 OP38 Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich Cheshire, CW 7LT 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 Woodleigh F51 F01 S37249 Woodleigh V235235 110805 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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