Inspection on 05/08/05 for Woodleigh Christian Care Home

This inspection was carried out on 5th 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 Christian Care Home 14/08/09

Woodleigh Christian Care Home 06/11/07

Woodleigh Christian Care Home 10/11/06

Woodleigh Christian Care Home 21/12/05

Woodleigh Christian Care Home 08/03/05

Woodleigh Christian Care Home 11/08/04

Woodleigh Christian Care Home 12/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Woodleigh Christian Care Home Norfolk Drive Mansfield Nottinghamshire NG19 7AG Lead Inspector Richard Ramsden Unannounced 5 August 2005, 10.30am th 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 Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodleigh Cristian Care Home Address Norfolk Drive Mansfield Nottinghamshire NG19 7AG 01623 420459 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) John Walton Rita Cooper Care Home With Nursing 40 Category(ies) of 40 - Old Age registration, with number 2 - Terminally Ill of places Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th March 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 Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors completed this unannounced inspection over one-day, it took approximately 6 hours. It included the inspection of care and other records, a discussion with two residents, two visitors, two members of staff and the registered manager. A partial tour of the building was also completed. What the service does well: The residents spoken with during this inspection were very happy with the care they receive and made many positive comments. They described the staff as helpful and considerate and said that staff ensure that their privacy and dignity is respected at all times. Visitors to the home also confirmed that they are very happy with the services provided to their relatives. The observed interaction between staff and residents was of a very good standard. The manager and staff make considerable efforts to ensure that residents and their families can influence the way in which the home runs. The home operates a ‘Friends Group’ that mainly consists of resident’s families and friends and meets in the home on a regular basis. (This is good practice). Residents are also provided with an impressive range of activities and entertainment. The residents said that they enjoyed the food provided at the home and there was evidence that alternative meals will be provided if people do not want them food suggested on the menu. The areas of the home viewed during this inspection had been well maintained and residents had been encouraged to personalise their rooms with pictures ornaments and small items of furniture. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 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 Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 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 Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 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) 3,6. The homes staff ensure that they can meet the needs of prospective service users by obtaining full written assessments prior to their admission to the home. The home does not provide intermediate care. EVIDENCE: Three residents records were checked during this inspection. An extended social work assessment had been obtained for each person prior to his or her admission to the home. The manager had also completed her own written assessment with two of the residents whose records were checked during the inspection. She stated that the third resident had visited the home prior to her admission but that she had not complete in a written assessment as the resident was only going to be admitted for respite care and no specific dates had been arranged at the time of the visit. The home does not provide intermediate care although they have provided the Step Down scheme in conjunction with the local council for residents being discharged from hospital. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 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) 7,8,9,10 Residents health, personal and social care needs are set out in individual care plans which are regularly reviewed to ensure that staff are always aware of what assistance and support each resident requires. Residents health care needs are being fully met, they are treated with respect and their right to privacy is upheld. Improvements need to be made to the way in which the homes medication is administered to ensure the safety of the residents. EVIDENCE: The residents care plans are created and reviewed on a computerised system, making it difficult to evidence the involvement of residents and relatives in the care planning and review process. One of the residents spoken with confirmed that she had been involved in the implementation and review of her care plan. One visitor stated that she is always informed of any changes to the way in which her mothers care is provided. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 Page 10 All of the care plans viewed during this inspection contained relevant information and were being reviewed and updated on a regular basis to reflect the individual residents changing needs. Risk assessments are included in the care plans where necessary. A record of contact with health care professionals was included in each care plan; this shows that a range of health care needs are being attended to. One of the residents spoken with during the inspection had recently returned from a three-day stay in hospital, she praised the health care being provided by the homes staff and her own doctor, stating that she was glad that she did not need to remain in hospital. The homes medication Administration records were checked at random and were well maintained. There were photographs of each resident adjacent to their Administration records to ensure that staff could check that they are administering the medication to the correct residents. The inspector was informed that only qualified nurses administer the medication at Woodleigh care home. The medication trolleys were locked and fastened to the wall at the time of inspection. However the refrigerator that contained medication was unlocked as was the door to the office in which the refrigerator was located. The senior staff was informed that medication must be stored safely at all times. There were many occasions when the temperature of the refrigerator in which the medication is stored had not been recorded. The senior staff was also informed that staff must record the temperature in the room in which the medication is stored, to ensure that the temperature does not exceed 25°C. The medication can deteriorate and become less effective if it is stored at a higher temperature. When the records of disposal of medication were checked at random the Inspector and staff could not locate the disposal records for 26 Temazepam tablets which had been prescribed for a resident prior to his admission to hospital. The manager stated that she believes that this medication was sent to the hospital with the resident, however there are no written records to confirm this. The manager was reminded that there must be a written record showing how all prescription medication has been disposed of. All of the residents spoken with during this inspection said that the staff are always friendly and respectful and that they ensure that their privacy and dignity is maintained at all times. The observed interaction between staff and residents was of a very good standard. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 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) 12,13,15. The residents are provided with an impressive range of activities and entertainment. Considerable efforts are made to encourage people to maintain contact with their family and friends. The diet provided for residents is wholesome, well balanced and varied. EVIDENCE: There were posters advertising the various events and activities displayed in the main entrance hall. (This is good practice). The home employs an activities organiser who works 20 hours a week. Both of the residents spoken with said that they are very satisfied with the stimulation provided within the home. Religious services are provided on a regular basis. The homes policy on visitors is included in the literature provided to prospective residents. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 Page 12 Two visitors to the home confirmed that they are always made to feel very welcome. Both of the residents spoken with stated that they can receive visitors at any time and that even their grandchildren are made very welcome. There is a Friends of Woodleigh Care Home group which resident’s friends and relatives are encouraged to attend. The group meets regularly and appropriate minutes of the meetings were displayed in the home. (This is good practice). The home has a four weekly rotating menu, which provides a choice of food at each mealtime. The diet appears varied and contains lots of fresh fruit and vegetables. The inspector was informed that where possible puddings etc are made with sugar substitutes so that people with diabetes can eat the same diet as the other residents. The inspector was advised that five people require liquefied diets. Each element of the meal is liquidised separately to preserve flavour and appearance. (This is good practice). Homemade soup and cakes had been prepared on the day of this inspection. The cook stated that if residents do not want the meal suggested on the menu an alternative would always be provided. Cooked breakfasts are available four days a week. At the time of inspection the work areas were appropriately clean however there was some food spillage and dust on the floor around the large refrigerators and freezers. The inspector was advised that these areas are thoroughly cleaned at least once each week. Both of the residents spoken with said that they are very satisfied with the food provided by the home, although one person who has a liquefied diet said that they would like more variation in the food provided at teatime. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 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) None None of the standards were assessed at this inspection. EVIDENCE: Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 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) 19,26. The accommodation is maintained to a very good standard. At the time of inspection the home was clean and there were no offensive odours. The laundry door must be kept locked when there is no staff in situ, failing to do this is putting residents health and safety at risk. EVIDENCE: A partial tour of the premises was completed as part of this inspection. The accommodation was well decorated, comfortably furnished and maintained to a good standard. The gardens are attractive and accessible to service users. The residents spoken with both said that they like their bedrooms. People had been encouraged to bring small items of furniture ornaments etc to personalise their individual rooms. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 Page 15 The laundry is well equipped with two industrial washing machines and two industrial tumble dryers. At the time of inspection the laundry was unattended and the door was left unlocked giving residents access to this room. The inspector was informed that there is no Key to lock the laundry door. This is not acceptable as there may be soiled, or infected linen in this room that would present a health and safety risk to the residents. It was also noticed that there was washing powder and fabric conditioner left attended in this room. The cosh data sheets were displayed in the sluice room adjacent to the laundry, it is recommended that the appropriate parts of the homes infection control policy be displayed in the laundry room. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 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. The manager must continuously monitor the residents dependency levels to ensure that there is always sufficient staff available to meet all of the residents assessed needs. EVIDENCE: The staff rota for the week of this inspection showed that the home is providing sufficient staff to comply with previously agreed staffing levels. However both of the residents and the visitors spoken with during the inspection said that they believe that the home is frequently short of staff, particularly in the mornings and evenings. When this was discussed with the manager she stated that the residents dependency levels have increased and that staff are having to work extremely hard to provide appropriate care to the resident group. The manager was advised that she must constantly assess the residents dependency levels and ensure that there are always sufficient staff to meet their assessed social, emotional and health care needs. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 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) None None of these standards were assessed as part of this inspection. EVIDENCE: Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 Page 18 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 Page 19 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 9 Regulation 13 Timescale for action It is required that the Immediate temperature in the refrigerator in 5/8/05 which medication is stored must be checked and recorded on a daily basis. It is required that the staff Immediate records, each day, the 5/8/05 temperature in the room in which medication is stored. The room temperature must not exceed 25°C It is required that the 5/9/05 refrigerator in which medication is stored is kept locked at all times when not being used by staff. It is required that a written Immediate record is kept showing how and 5/8/05 when prescription medication has been disposed of. It is required that the laundry 5/9/05 door is kept locked when there are no staff in situ. It is required that hazardous Immediate substances are kept securely at 5/8/05 all times. It is required that the manager Immediate constantly assess the residents 5/8/05 dependency levels to ensure that there is always sufficient staff on duty to meet there are assessed Version 1.40 Page 20 Requirement 2. 9 13 3. 9 13 4. 9 13 5. 6. 7. 26 26 27 13 13 16 18 Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc social emotional and health care needs. 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 26 Good Practice Recommendations It is recommended that the relevant sections of the homes Infection Control Policy are displayed in the laundry. Woodleigh Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 Cristian Care Home C53 C02 S39728 Woodleigh V243093 050805 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!