CARE HOMES FOR OLDER PEOPLE
Woodleigh Manor Woodfield Lane Hessle East Yorkshire HU13 OEW Lead Inspector
Mavis Pickard Unannounced Inspection 13 February 2006 11:00 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 Manor DS0000019776.V277537.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 Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Woodleigh Manor Address Woodfield Lane Hessle East Yorkshire HU13 OEW 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) 01482 359919 01482 359929 Hessle Properties Limited Miss Donna Marie Taylor Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (31) of places Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th September 2005 Brief Description of the Service: Woodleigh Manor is a former large private dwelling situated in a residential area of Hessle in East Yorkshire that has been converted into a care home for older people some of who may have a dementia type illness. Much of the building’s traditional character has been retained. The communal rooms are situated on the ground floor and private bedrooms arranged over two floors. There is a shaft lift for less ambulant residents. Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by 1 Inspector over a four-hour period. The registered manager was not available and the inspection was assisted by the person in charge[ PIC] on the day, Debbie Offen. Before the conclusion of the inspection Mrs Offen had to leave the premises to deal with another care home matter, therefore with her agreement the feedback to this visit was provided the following day by telephone and a requirement/recommendation feedback form was sent by post to the home. During the visit the home was running well, residents and staff presented as being relaxed and interacting with each other in a respectful way. There were 30 residents accommodated on the day of inspection. What the service does well: What has improved since the last inspection?
The person in charge said that the redecoration programme is continuing. Carpet and flooring has been replaced in a number of areas. The programme of providing radiator covers is completed and there is an ongoing programme of replacing beds.
Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 6 The home now employs an activities organiser over 5 days Monday to Friday. Care plans are being systematically reviewed; there are records of the care provision and detail of the care delivery. The medication system, which was recorded in the previous inspection report as not being operated in a manner that ensures the system is free from misuse, was examined during this visit. There were no major issues. Controlled medication was being signed for by two people. All people who administer medication are trained so to do. Medication is stored in a locked trolley that is stored in a locked cupboard. 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 Manor DS0000019776.V277537.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 Manor DS0000019776.V277537.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): None of the above standards were assessed at this visit. EVIDENCE: Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Resident’s care needs are set out in individual care plans. Resident’s health care needs are met. Medication practices are safe. It is not clear that the dignity of resident’s dignity is always respected. EVIDENCE: From records examined it is clear that the assessed needs of people accommodated is set out in a comprehensive care plan document that evidences the care to be provided and how it is to be delivered. The examination of care plans and direct observation shows that the health care needs of people living at the home are recognised and met. Concerns were raised with the person in charge [PIC] in respect to the observed use of wheelchairs [please refer to Standard 22] Medication records were examined and administration practices observed. No concerns were noted. However the PIC said that there are some prescribed
Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 10 medicines in the home’s monitored dosage cassettes that are no longer required. It was discussed that these medicines will be returned to the pharmacy on the regular collection date, which is a monthly occurrence. Advice was given that this practice is acceptable so long as the unwanted medications are stored securely and separately from the ones in current use. During the tour of the building it was noted that residents bed clothing [nightdresses and pyjamas] are stored in the most used communal bathroom. Although the PIC said that all the items are named and residents would only be dressed in their own items, this practice is not acceptable and does not show respect to residents or uphold their dignity. Residents clothing should be stored in their private accommodation and brought to the bathroom along with their toiletries and/or continence products when they are required for use by the individual. Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14 The home provides an excellent activities programme. Residents are not always supported to exercise choice. EVIDENCE: The home employs an activities organiser, Barbara who works Monday through Friday for about 6 hours a day. The records she maintains are set out well and give good evidence of the provision. Photographic evidence of the provision is made available and shows which residents have taken the opportunity to join in. The written record sets out where people sit and gives detail of how long the activity lasted and the outcome for residents. The photographs evidence that people accommodated enjoy what is provided and take pleasure in activities such as baking, bingo, quizzes, craftwork and many more pastimes. Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 12 Barbara said that she ensures that people who don’t want or aren’t able to join in group activities have 1-1 time with her for conversation, reading or whatever they wish, that is able to be provided. The way in which activities are provided by the home and the way in which records are maintained is to be commended. As reported previously in this report, residents are not always able to exercise control over their lives in respect to where their personal clothing, and/or continence products are stored. [Please refer to standard 10] Woodleigh Manor DS0000019776.V277537.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): These standards were not assessed at this visit. EVIDENCE: Woodleigh Manor DS0000019776.V277537.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): 22 and 26 Specialist equipment is used inappropriately. Some areas of the home are not free from unpleasant odours. EVIDENCE: Residents were observed during their lunchtime. Some people were taking their meal sitting in wheelchairs. It was not clear from speaking with the PIC if wheelchairs being used had been provided specifically for the individuals who were using them. It was observed that people were slumped in ‘their’ wheelchair and that their backs were not being supported. During discussions with the PIC and other staff it was indicated that ‘they liked it like that’. It is difficult to understand that this could be the case. The PIC said that sometimes an ordinary cushion was used to ‘prop’ them up and/or make them more comfortable.
Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 15 Residents were noted not to have been provided with footrests for the wheelchair whilst at the dining table. It was indicated by the PIC that the ‘chairs would not fit under the table had they been fitted with footrests. This situation is not acceptable. Where residents need to be seated substantially or for long periods of time in a wheelchair they must be assessed for their own chair where appropriate back cushions and footrests would be provided. This equipment must then be used by staff for the safety and comfort of residents. If wheelchairs are used for transport to the dining table or elsewhere, residents must be transferred to an appropriate chair that they can sit in safely and comfortably with their feet on the floor and their back supported. During a tour of the building malodours were detected in some private accommodation. The PIC indicated that this was impossible to deal with and that it was caused by the residents ‘personal odour’. This explanation is not acceptable. Where unpleasant odours are detected steps must be taken to eradicate them. Woodleigh Manor DS0000019776.V277537.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 and 30 The home employs sufficient staff. Staff undertakes regular and appropriate training to do their jobs. EVIDENCE: The up to date staff rota and training matrix evidences that the home employs sufficient staff to meet the needs of residents and that staff undertake regular training on a range of care related topics including dementia. Staff presented as being very busy however, the PIC said that in her opinion as an experienced care worker, on the day of inspection there were sufficient staff to meet people’s needs. Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 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 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): 33,37and 38 The home undertakes regular quality assurance surveys. Not all parts of the home are safe. Not all records are made available for the purpose of regulation EVIDENCE: A requirement of the previous report had been in respect to the registered person seeking the views of residents, relatives and/or representatives about the services provided by the home. It was reported then that no records were available regarding outcomes of any survey undertaken. During this visit it became clear that surveys had taken place and that records were available. These records and outcomes were examined. The records show
Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 18 that interested parties were asked by the use of a survey format, what they thought about the services provided by the home. The completed forms were available showing that in the main positive replies although some concerns were raised. What is not recorded is what actions were taken to resolve any concerns. The PIC said that any issues raised had been dealt with appropriately, however any record of the resolution was not made available for the purpose of regulation. It’s required that the records be made available to inspectors and to anyone who may have an interest in them. It is additionally noted that a requirement of the previous several inspections, is that the providers Regulation 26 reports made by him as a provider who is not in day to day control [management] of the home are not made available for the purpose of regulation. This requirement is made again. During the tour of the building it was noted that the fire exit routes in one area were not appropriately signed. This needs to be rectified. Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X 1 X X X 1 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X X 1 1 Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP10 Regulation 12(4)(a) Timescale for action The registered person must 13/02/06 make arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of people accommodated. The registered person must 13/02/06 ensure that where specialist equipment is provided e.g. wheelchairs, the individual has been assessed by a suitably qualified and/or trained person for the equipment and that the equipment is used appropriately for the safety and comfort of the individual. The registered person must 30/09/05 ensure that all parts of the home are free from offensive odours. When the regsitered person is an 13/02/06 individual and is not in day-today control of the home he must visit the home in accordance with Regulation 26 of the Care Homes Regulations 2001 and make his reports available for the purpose of regulation. This requirement is not met
Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 21 Requirement 2. OP22 14(1)(a) 23(2)(c) 3. 4. OP26 OP37OP33 16 26 in respect to the previous several reports. [Requirements first dated 31/4/04] 5. OP38 23(4) (c)(iii) The registered person must 13/02/06 following consultation with the fire authority take adequate precautions for the evacuation of, in the event of fire, all persons in the care home by ensuring that all evacuation routes are suitably marked. The registered person must 13/02/06 following consultation with the fire authority take adequate precautions for containing fire with reference to the use of door wedges in the laundry area. 6. OP38 23(4) (c)(i) 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 9 Good Practice Recommendations The registered person should ensure that prescribed medication that is discontinued and/or no longer required is stored securely and away from the medication cabinet. In readiness for its collection by the pharmacist. The registered person should ensure the health and safety of people working in the laundry area in respect to adequate ventilation. 2 38 Woodleigh Manor DS0000019776.V277537.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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