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Inspection on 21/12/05 for Woodleigh Christian Care Home

Also see our care home review for Woodleigh Christian Care Home for more information

This inspection was carried out on 21st December 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The environment is pleasant, bright and smelt fresh. To promote a homely environment service users bedrooms are pleasantly and individually decorated and furnished to the service users own tastes. It is evident that service users have lots of personal possessions in their rooms to further promote the homely atmosphere. The staff employed at the home are provided with the opportunity to attend training courses to promote the safety and well being of the service users and staff alike.

What has improved since the last inspection?

The acting manager has implemented all the recommendations formulated at the last inspection. Improvements have been made in relation to the way in which medication is stored to ensure that the system is safe for the residents. The records showing how prescription medication has been disposed of are now maintained. The door to the laundry room is now kept locked when there is no staff in the room and appropriate sections of the homes Infection Control Policies are displayed in the laundry.

What the care home could do better:

Evaluation and care planning documentation formulated on a computerised system identified significant shortfalls in both the care planning and evaluation process and as such the health care needs of the case tracked service users was not being addressed effectively at the home. A upstairs room which is used to store dressings and medical equipment for use in the home was not secure and as such could present a potential risk to service users.

CARE HOMES FOR OLDER PEOPLE Woodleigh Christian Care Home Woodleigh Christian Care Home Norfolk Drive Mansfield Nottinghamshire NG19 7AG Lead Inspector Steve Keeling Unannounced Inspection 21st December 2005 08:00 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 Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 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 Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodleigh Christian Care Home Address Woodleigh Christian Care Home Norfolk Drive Mansfield Nottinghamshire NG19 7AG 01623 420459 01623 460381 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 John Richard Walton Dr Gail Margaret Walton Rita Cooper Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Terminally ill (2) of places Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th August 2005 Brief Description of the Service: Woodleigh Christian Care Home is situated 100 yards from Chesterfield Road which has a bus route into Mansfield town centre, approximately half a mile away. The property is an attractive two-storey, Victorian building which has been extended in the last 10 years. It provides nursing and residential care for up to 40 older people in single and twin bedded rooms some of which have ensuite facilities. There is a shaft lift to assist independent access between floors. There are two lounges and two separate dining rooms. A well maintained enclosed garden provides a safe outdoor area and is accessible to all of the residents, there are also car-parking facilities on site. The home is run on Christian principles but accepts older people from other religions and cultures. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a 4.5 hour period and involved one inspector. The main method of inspection was case note tracking, this is a method of selecting service users within the home and discussing with them their expectations and experiences of living within the home environment. The case tracking method also analyses the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the care home setting and that their safety and well being is being maintained. On this occasion two residents notes were case tracked. Also as part of the case tracking process, staff members within the home are informally interviewed to further evidence the quality of care afforded to the service users. At the time of the inspection a total of 30 residents were accommodated at the home. It was evident that the acting manager and staff within the home are very committed to providing a high standard of care for the service users. The manager and staff within the unit were very helpful and cooperative thus ensuring that the inspection process progressed in a professional and efficient manner. What the service does well: The environment is pleasant, bright and smelt fresh. To promote a homely environment service users bedrooms are pleasantly and individually decorated and furnished to the service users own tastes. It is evident that service users have lots of personal possessions in their rooms to further promote the homely atmosphere. The staff employed at the home are provided with the opportunity to attend training courses to promote the safety and well being of the service users and staff alike. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 6 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. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 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 Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home has admitted a service user who is “out of category” and it could not be established that her profound learning disabilities were being addressed effectively at the home. EVIDENCE: It was evident that a case tracked service user who had been diagnosed as having profound learning disabilities had been admitted to the home although the home is only registered for Old Age (40) Terminally ill (2). An examination of the service users care plans evidenced that the complexities of caring for individuals with profound learning disabilities had not been addressed effectively at the home as no care plans were evident which highlighted her learning disability needs. The Commission for Social care Inspection will require the registered person to evidence the rationale for accommodating a service user who has profound learning disabilities and evidence that the home is providing training opportunities so as to ensure the staff at the home can address the individuals needs effectively. Once appropriate documentation has been provided to the Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 9 Commission for Social Care Inspection a decision will be made as to the need to apply for a minor variation in relation to the registration of the home. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8. 9. The case tracking procedure established that the care plans examined did not fully address the health needs of the service users and as such it could not be established that health needs were being fully met at the home. No service users within the home are responsible for the administration of their own medication at the time of the inspection, although facilities for selfadministration of medicines are available should it be required. EVIDENCE: The documentation of two service users was case tracked at the time of the inspection. The two case-tracked care-planning documentation did not contain effective care plans to address all the identified needs. A service user at the home was receiving nursing interventions for the treatment of a sacral pressure sore. The identified goal on the care plan was for the pressure sore to heal and prevent reoccurrence; the care plan did not give any indication as to the required nursing/care interventions to achieve the Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 11 identified goal and it was established through discussions with the nursing staff that the pressure sore had developed into a sinus but this was not addressed on the care plan. Continued examination of the care plans, which are formulated on the computerised system utilises at the home, evidenced significant shortfalls in relation to the identification of needs, goals and the nursing/care interventions required. It was evident that on many occasions the aforementioned elements of care were completely blank and as such it could not be established that the care being received at the home was conducive to maintaining an optimum health status for the service users. A case tracked service user had elevated Waterlow Score of 23 (Waterlow is a tool to determine an individuals susceptibility to the formation of pressure ulceration). A care plan was not evident to evidence that the appropriate interventions are taking place to minimise the risk of pressure ulcer formation. The home maintains daily progress documentation within the computerised system for all service users in which elements of care identified in care plans should be evaluated effectively. It was evident that the evaluation process was somewhat sporadic and not effective. The daily evaluation records evidenced comments such as “no problems to report” which is not an effective evaluation of the care plans. The acting manager of the home confirmed that elements within the care planning and assessment process requires further development and it was established that she would be addressing the shortfalls on the computerised system in the very near future. The Commission for Social Care Inspection issued a requirement to address the identified shortfall and will be monitoring the acting manager’s progress at the next inspection. At the time of the inspection no service users were responsible for the selfadministration of medicines. It was established that should a service user wish to be independent in the administration of medicines the manager would perform a risk assessment, if the service users was deemed as being safe, selfmedication would be facilitated if at all possible. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Service users are encouraged to exercise choice and control over their lives although no formal consultation process is currently employed at the home. EVIDENCE: It was established that service users are afforded a choice in relation to varied social activities and wholesome meals at the home but it was established that service users are not afforded the opportunity to express opinions and concerns within an open forum such as a residents meeting. Residents meetings are intended to identify issues relating to the care provided to service users at the home so that any issues of concern can be discussed and addressed effectively. Residents meetings could also provide a forum to discuss plans for the development of the home so as to include service users in this process. The acting manager of the home confirmed that the consultation process is somewhat lacking and she intends to address the shortfall in the New Year by creating a residents forum. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 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 complaints procedure utilised at the home is effective and the inspector was confidant that any concerns or complaints will be listened to, taken seriously and acted upon by the manager. Residents are protected by the policies and procedures at the home. EVIDENCE: The home benefits from clear policies and protocols relating to the reporting of concerns and complaints, the complaints procedure is available in the home foyer for service users and their representative’s perusal. At the time of the inspection no complaints were being investigated at the home and no complaints have been received at the Commission for Social Care Inspection. All staff receives appropriate training in relation to the reporting of complaints And staff spoken with were fully aware of the homes policies in relation to the protection of vulnerable adults and were aware of what actions would be required it they suspected abuse was happening within the home setting. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 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 the following standard(s): 26. The home provides a safe well-maintained environment for service users. The home is in excellent decorative condition, very clean and smelt fresh. EVIDENCE: A partial inspections of the home evidenced that the home provides a very spacious, clean and well-decorated environment for service users. The home benefits from an enclosed, well maintained garden area, which is accessible to the service users. It was evident that service users had many personal possessions in their bedrooms such as family pictures, ornaments, televisions and radios thus promoting a homely environment for the residents. At a previous inspection a requirement was made to ensure that the laundry room was locked when not in use. The door to the laundry room is now kept locked when there is no staff in the room and appropriate sections of the homes Infection Control Policies are displayed in the laundry. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 15 Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 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 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, 29, 30, Staffing levels employed within the kitchen area is not conducive to maintaining an effective catering service at the home. The manager of the home ensures that the recruitment process utilised at the home is effective in ensuring the safety of the service users. Care staff within the home receive appropriate levels of training to ensure the service users are in safe hands at all times. EVIDENCE: Staff files examined evidenced appropriate documentation to ensure the vulnerable service users are protected. The staff files examined contained Criminal Records Bureau checks (CRB) and two satisfactory references, it was established that no members of staff are now employed at the home until the aforementioned checks have been undertaken and are satisfactory. Staff employed in the delivery of care at the home had been inspected previously and was assessed as sufficient in meeting the needs of the service users and an appropriate skill mix was evidenced at that time. The inspector had concerns in relation to the staffing levels utilised in the kitchen / food preparation area. On the day of the inspection only one member of staff was employed to provide the 30 service users with wholesome, varied and appetising meals throughout the day. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 17 The same member of staff was expected to ensure that the kitchen is maintained to an appropriate standard of cleanliness and hygiene. Although two staff are employed to cover seven days in the kitchen are it was established that once days off are taken into consideration the home runs with only one member of staff in the kitchen for four day per week. This staffing level is not conducive to maintaining an effective catering service at the home and as such the staffing levels in the kitchen will be reviewed as a matter of priority. The Commission for Social Care Inspection issued a requirement to address the identified shortfall and will be monitoring the acting manager’s progress at the next inspection. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 18 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. 35. 38. Service users are protected from financial abuse and their financial interests are safeguarded. The health and safety of service users is promoted at the home through a ongoing comprehensive maintenance programme. EVIDENCE: The acting manager at the home has only been in post four one month and her application to be registered with the Commission for Social Care Inspection as the registered manager has not been received at the Commission. The inspector highlighted the need to provide the Commission with all the relevant documentation at the earliest opportunity so that the acting managers application can be processed effectively and her suitability in performing the manager’s role at the home can be determined. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 19 At the time of the inspection it was evidenced that the service users monies are effectively managed. A clear record of monitory transactions could be evidenced. The case tracked service users, monies are securely stored, in individual plastic folders and stored within a secure environment. Receipts are evident for all transactions performed, and a clear financial audit trail was evident thus protecting the service users from financial abuse. It was evidenced that the home is maintained to a satisfactory standard throughout and it was determined that appropriate precautions are taken in relation to the control of Leginalla contamination, the testing of emergency lighting, the testing of fire equipment and fire alarms. It was also evidenced that the acting manager of the home with the aid of a maintenance technician employed for 20 hour per week, performs appropriate maintenance on all equipment designed of aid mobility such as wheelchairs, hoists and specialist baths. Hot water outlet checks are performed on a monthly together with the staff call system, which is also checked monthly. The records appertaining to the all the aforementioned issues were clear, concise and well maintained by the maintenance technician. A partial inspections of the home evidenced that room 44 is currently being used as a storage are for dressings, Percutaneous Endoscopic Gastrostomy (PEG) feeds and other equipment utilised in the treatments of service users at the home. The room was not secure or temperature monitored, it is necessary to store some types of dressings and PEG feeds within a controlled environment to prevent degradation and a requirement was made at the time of the inspection to secure the room to promote the service users safety. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 x x 3 Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 21 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 3 Regulation 14 (1) (a) (b) (c) Requirement The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so— The needs of the service user have been assessed by a suitably qualified or suitably trained person; The registered person has obtained a copy of the assessment and there has been appropriate consultation regarding the assessment with the service user or a representative of the service user 28/02/06 The registered person shall ensure after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. 28/02/06 The registered person shall, for the purpose of providing care to service users, and making proper DS0000039728.V274723.R01.S.doc Version 5.1 Page 22 Timescale for action 28/02/06 2 8 15 (1) 3 14 12 (3) Woodleigh Christian Care Home 4 27 18 (1) (a) provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings. The registered person shall ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users 28/02/06 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 8 Good Practice Recommendations Room s that are being refurbished/redecorated should be locked so as to prevent service users access to tools and sharp objects. All care staff employed at the home should be familiar with the process of accessing information from the computerised care planning system to promote effective communication of service users needs. Woodleigh Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Christian Care Home DS0000039728.V274723.R01.S.doc Version 5.1 Page 24 - 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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