Inspection on 06/06/07 for Woodleigh

This inspection was carried out on 6th June 2007.

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 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 16/12/05

Woodleigh 16/08/05

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 Ms Julie Porter Unannounced Inspection 6 June 2007 13:45 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 Woodleigh DS0000037249.V343828.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 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 DS0000037249.V343828.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodleigh Address Callands Road Callands Warrington Cheshire WA5 9RJ 01925 235237 01925 242571 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) Warrington Borough Council Mrs Marine Hall Care Home 39 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (12), Mental disorder, excluding learning of places disability or dementia (15), Mental Disorder, excluding learning disability or dementia - over 65 years of age (15), Old age, not falling within any other category (39), Physical disability (4), Physical disability over 65 years of age (4) Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 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) * Up to 4 service users in the category of PD(E) Physical disability over 65 years) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection 16th December 2005 2. 3. Date of last inspection Brief Description of the Service: Woodleigh is a community support centre for older people and people with disabilities 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 people needing residential personal care and there is a 25 place day centre in the same building. The home also has close links with the local authoritys care at home 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 DS0000037249.V343828.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on the 06 June 2007 and lasted 5.5 hours. The visit was carried out by one inspector. This visit was just one part of the inspection. Before the visit the owner manager was asked to complete a questionnaire to provide up to date information about the home. CSCI questionnaires were also made available for people who use the service, families, and health and social care professionals to find out their views. During the visit various records and the premises were looked at. A number of people who use the service and their family members were also spoken with; they gave their views about the service. What the service does well: What has improved since the last inspection? Following a recommendation of the fire officer intumescent strips have been fitted to all the fire does so that people staying in the home are further protected in the event of a fire there. The exterior of the property has been painted since the last inspection to improve the surroundings for the people who live and stay at the home. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 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 Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the people who may use the home are assessed before they are offered a service to ensure that their needs can be met at the home. EVIDENCE: The home has a brochure that details what services are on offer to people staying there. It does not contain the details required about the experience and qualifications of the manager and staff, or what people should do if they become unhappy with any aspect of the service. Following the visit information was received that the brochures are being reprinted later this year and will include information as stated in Schedule 1. There are specific criteria for obtaining a service at the home for permanent or respite care; a full needs assessment is undertaken by a qualified person before anybody can move into the home to check that they meet the criteria and their needs can be met there. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 9 The home does not offer intermediate care. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health of people using the home is monitored so that they receive the care/support that they need. EVIDENCE: Each time a person comes to the home for respite care accurate and up to date information is recorded on their plan, the service user preference sheet and the care programme. Two plans were inspected but had not been signed or dated by staff responsible for updating them. Care plans for people who live at the home long term showed they were being regularly reviewed by senior staff and that people’s health care needs were being monitored. In addition a daily record is kept about each person’s activities for that day. This was checked in respect of a conversation with one resident and was found to be accurate. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 11 Evidence was seen that people who live and stay at the home could use the visiting optician and chiropodist unless they wish to make other arrangements. The district nurse had visited the home on the day of the visit to check and renew dressings for one of the people living at the home. All the people who live at the home long term are registered with a GP. People who come to the home for respite keep their own GP unless they need emergency medical treatment. One person was taken to hospital by ambulance on the day of the visit, but returned to the home later that evening. There are policies and procedures for medicine administration. During the visit the medicine records were inspected and the staff were watched giving people their medicines after the evening meal. Medicine records were maintained appropriately. However, on three separate occasions, the medicine trolley was seen stored against a wall but it was not secured. Residents can keep and manage their own medicines subject to a satisfactory risk assessment. The home has a two part risk assessment to make sure that people understand why they need to take their medicines and consent forms for those people who will be keeping and managing their own medicines. Part two involves the staff assessment of their understanding. A completed assessment was seen and signed by the resident; however the staff had not signed the relevant paperwork to confirm that they felt the person was able to manage their own medicines. Staff were observed during the visit preparing the residents for tea, chatting, and preparing for having a bath. Staff attitudes were warm, caring and friendly. Staff were seen knocking on doors and speaking with people politely. Residents said that staff were “lovely”, “very polite” and that they always knock on their bedroom doors and wait to be invited in. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is little opportunity for people living and staying at the home to take part in activities so they may lose the capacity to maintain their skills and/or develop new interests. EVIDENCE: During the visit staff were seen working hard on daily tasks such as tidying up, vacuum cleaning and washing dishes. There were few opportunities to sit and talk with residents or plan/take part in activities. One relative spoken with raised concerns about the lack of stimulating activity offered to her relative during their stay for respite. This was discussed with the manager of the home who explained that they do not currently have an activities coordinator. The manager and senior staff reported that occasionally there are opportunities for the home and the adjacent day care centre to join together for activities particularly when an entertainer is booked. Staff were seen during the visit making arrangements for the next day to go with a group of permanent residents to see a matinee performance at local theatre. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 13 Visitors were seen coming and going throughout the day; one visitor had travelled for the day to spend time with her friend and said that they had enjoyed having lunch in the home together. Some of the bedrooms were seen and all had been personalised to varying degrees. People at the home are encouraged to manage their own finances for as long as possible; some residents have support of their family to do this and small amounts of personal money can be kept in the safe at the home if necessary. The evening meal was observed during the visit; it consisted of sandwiches or scrambled egg with a dessert. The main meal of the day is served in the home at lunch. All the people living or staying at the home and one visitor spoken with were very complimentary about the quality and quantity of the food served. Menu plans were checked and showed a good selection of meals and alternatives. The cook said she knew the dietary needs of all the people at the home well, including their individual likes and dislikes and need for special diets such as pureed food. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there are policies and procedures in place, in the absence of up to date training for all the staff, people who live and stay at the home may not be fully protected from possible abuse, harm or poor practice. EVIDENCE: Warrington Borough Council has a complaints procedure that the relatives are referred to should they be dissatisfied with any aspect of the service. Information about the complaints process is not included in the home’s brochure. The complaints record was checked and showed that two complaints had been received by the home. Both had been investigated and responded to. One complaint identified that a resident had fallen and it was noted that the Commission for Social Care Inspection had not been notified of the incident as required under Regulation 37 of the Care Homes Regulations 2001. Evidence was provided by the manager on 11/06/07 with a record of all other verbal complaints/compliments made by residents and included the action taken by staff to resolve the matter. Information provided before the inspection and on 11/06/07 regarding adult protection/vulnerable adults/adult abuse training does not show that all staff Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 15 have received this training. The manager’s covering letter states that all staff have undergone this training at induction. Training relating to adult protection should be in line with Department of Health guidance “no secrets” and staff should be regularly updated. The manager confirmed that one referral has been made to the local authority’s adult protection team and she is waiting for the minutes of the meeting that was held. The Commission for Social Care Inspection has not been informed of this matter as required under Regulation 37. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained so the people who stay there live in safe, clean comfortable surroundings. EVIDENCE: The home has five living areas each containing a lounge/dining room with a fitted kitchenette, bedrooms (some of which are en-suite), 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 areas are kept clean and well maintained. Service contracts were seen for specialised baths and the home’s alarm call system. One person who was spoken with said that she enjoyed the opportunity to have a nice long soak in the bath when she was staying for respite care. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 17 In April 2007 there was a fire in the home and as a result the laundry was destroyed. The investigation has now been concluded and the fire officer believes the equipment was faulty and the fire therefore unavoidable. The alternative arrangements made to manage people’s laundry have worked well and none of the residents spoken with felt that there had been any disruption caused by the lack of on site facilities. Intumescent strips have now been fitted to all fire doors following the recommendation of the fire officer. The exterior of the property has been painted since the last inspection Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Thorough recruitment procedures are followed and staff receive training, not all of them have received up to date training to make sure they can keep the people who staying in the home safe. EVIDENCE: The home manager said that in discussion with senior staff they adjust the staffing levels according to the known needs of the people who live at the home long term and the assessed needs of the people who come to the home for respite care. The information provided by the manager before the visit showed that 12 care staff have achieve National Vocational Qualification (NVQ) at level 2 or above in care and a further 6 are due to complete an NVQ this year. Warrington Borough Council operates a thorough process in respect of recruitment, which includes application forms, references, Criminal Record Bureau (CRB) disclosure and a medical prior to staff starting work. Warrington Borough Council has a comprehensive plan for training. However information provided before the visit and subsequent information provided on 11 June 2007 did not adequately demonstrate that all staff have achieved Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 19 mandatory training. Some staff training was out of date and some had not attended training relating to moving and handling, health and safety, emergency aid and food hygiene. Warrington Borough Council’s guidance is that staff attend fire awareness training every 3 years, this was discussed with the manager of the home and for her to seek advice from the fire officer in relation to frequency and suitability of the training delivered. Records showed that current Warrington Borough Council’s guidance is not being followed in that some staff have not received training for fire prevention in the last three years. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the management arrangements run well, staff have not achieved all mandatory training in relation to health and safety and therefore cannot adequately demonstrate they have the skills and knowledge to safeguard the welfare of the residents. EVIDENCE: The manager of the home is qualified and registered with the Commission for Social Care inspection. During the visit she was seen around the home speaking with people who stay there and staff. People who stay at the home who were spoken with said they knew who the manager was and said that they see her a lot. Comments from one relative of a person using the service spoke of the manager as “exceptional.” Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 21 Monthly visits, to check how the home is being run and to comply with regulation 26 of the Care Homes Regulations, are carried out by staff from the contract and policy department of Warrington Borough Council. Copies of their reports were available in the home. People who live and stay at the home are encouraged to manage their own finances for a long a possible. Lockable storage is available in their bedrooms to store valuables and a small amount of money can be deposited in the home’s safe. One person’s finances are managed by staff at the home. The arrangements for this were checked at the last inspection and were found to be satisfactory so were not looked at again at this visit. Information was provided before the visit regarding the service contracts for equipment in the home. A sample was inspected and found to be satisfactory. Accident records were inspected and found to be satisfactory. All staff have not achieved mandatory training and therefore the home cannot guarantee the staff are working in line with current guidance. Woodleigh DS0000037249.V343828.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 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 3 X X X 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 X 3 X X 2 Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 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 2 Standard OP9 OP12 Regulation 13(2) 16(2)(n) Requirement The medicine trolley must be stored securely to make sure that it does not go missing. Residents must be consulted with about and provided with a range of activities to suit their needs, preferences and interests. Any occurrences that affect the wellbeing of any resident must be reported to the Commission for Social Care Inspection without delay. Staff must receive updates on training in Adult Protection so that they can safeguard residents’ welfare Staff must receive up to date mandatory training in relation to fire awareness, 1st Aid, moving and handling and food hygiene so that residents are supported safely. Timescale for action 07/06/07 31/07/07 3 OP8 OP18 37(1) 07/06/07 4 OP18 13(6) 31/08/07 5 OP30 18(1)(c) 31/08/07 Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 24 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 3 4 Refer to Standard OP1 OP7 OP9 OP38 Good Practice Recommendations The information included in the statement of purpose should be reviewed so that it complies with Schedule 1. Care plans for people using the respite service must be signed and dated to show that the information is current. Staff should sign and date risk assessments to show that the information is up-to-date The fire officer should be consulted to check that the frequency and content of staff training on fire safety is satisfactory. Woodleigh DS0000037249.V343828.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000037249.V343828.R01.S.doc Version 5.2 Page 26 - 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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