Inspection on 19/09/05 for Woodleigh Manor

This inspection was carried out on 19th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodleigh Manor 13/08/07

Woodleigh Manor 31/08/06

Woodleigh Manor 13/02/06

Woodleigh Manor 15/11/04

Woodleigh Manor 09/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodleigh Manor Woodfield Lane Hessle East Yorkshire HU13 OEW Lead Inspector Pam Dimishky Unannounced Inspection 19th September 2005 09:30 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.V249991.R01.S.doc Version 5.0 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.V249991.R01.S.doc Version 5.0 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.V249991.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2004 Brief Description of the Service: Woodleigh Manor is a large period building situated in a quiet suburb of Hessle. The property has been converted from a private residence to a care home for up to 31 older people over the age of 65, some of whom suffer from dementia. Much of the building’s traditional character has been retained and provides a pleasant environment for the residents. There is a large sitting room, pleasant oak panelled dining room and quiet room. A covered courtyard with fountain and exotic plants provide an alternative seating area. Bedrooms, most of which are for single occupancy, are pleasantly furnished and residents are encouraged to personalise their room with small items of furniture and memorabilia. A lift provides an alternative route to the first floor for residents who are less ambulant. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over eight hours (including preparation time) and was carried out by one inspector. One requirement from the previous inspection remains outstanding. The inspector looked around all areas of the home and a number of records were inspected. The inspector spent some time with the residents and in particular eight of the thirty residents were spoken to; two members of staff were interviewed. The inspection has carried out in the presence of the deputy manager as the manager was on holiday. What the service does well: What has improved since the last inspection? The redecoration programme is continuing with many areas having been painted and decorated since the last inspection. Carpet and flooring was also seen to have been replaced in a number of areas. The programme of providing radiator covers is also almost completed and there is an ongoing programme of replacing beds. Complaints are recorded, fully investigated and resolved where possible. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 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. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 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.V249991.R01.S.doc Version 5.0 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): 1,3 and 6 Prospective residents have their needs assessed prior to coming into the home which ensures that the home is confident they can meet the needs. The home is not registered to provide for intermediate care. EVIDENCE: The deputy manager stated the manager visits prospective residents in either hospital or their own home to assess the needs prior to moving into the home. However, in two of the four case files examined there was no evidence of this assessment. (The manager was not present at this inspection but later confirmed the assessment is kept separately once the care plan is developed). Assessments and care plans provided by social services care management are also obtained where applicable. Confirmation that the home can meet the resident’s needs is included in the contract. Whilst residents said they did not have any information about the home, an information pack was seen in one bedroom. However, a social service review for one resident dated 28.7.05, stated “an information pack to be made available”. (The manager later confirmed that the resident has received several copies of the information pack.) The home does not provide for residents assessed for intermediate care. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 9 Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 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): 7,8,9 and 10 Residents care plans generally have sufficient detail to provide staff with the information they need to satisfactorily meet residents assessed needs. However, these are not always up to date and daily records do not always provide sufficient evidence the care plan is being met. The medication system needs tightening up to ensure drugs are correctly recorded and can be reconciled with the drugs being kept. Until this is done there is a potential for abuse. Personal support is offered in such a way as to promote and protect residents privacy, dignity and independence. EVIDENCE: Care plans are generally comprehensive although two of the four examined were for residents relatively recently moving into the home and these indicated areas which were concerning, eg daily notes in one referred to the district nurse advising the resident’s legs should be elevated. The resident was observed sitting in a wheelchair with legs dangling and no footrests in place. The deputy manager stated the resident had refused to elevate her legs but there was no documentation to evidence this. Another resident had a review with social services on 28.7.05 and the outcomes listed had not been incorporated in the care plan and there was no evidence to suggest any of the Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 11 changes were being made. The care plan for one resident who has unfounded fears about continued occupancy in the home did not evidence these fears which are clearly a great concern to the resident. The inspector advised it may be of help to provide reassurance in writing so the resident can continually refer to this; the care plan must be updated to reflect the fears and the action to be taken so they can be addressed. The manager reviews care plans monthly and this is recorded. Medications are being appropriately stored and records were principally examined for four residents; medications must not be kept for one person not living in the home. The majority of the MAR (Medicine administration record) sheets were loose and not in alphabetical order which was confusing. Temazepam prescribed for one resident could not be reconciled with the records, indicating three tablets too many. The deputy manager stated that a further 60 tablets had been prescribed and her usual practice is to return the extras to the pharmacist and commence the new prescription. One resident had Lactulose stored in a bedroom cabinet which does not lock and a risk assessment for self-medication had not been made. Two residents selfmedicate and have risk assessments, regularly reviewed, and lockable storage in their room to support their wish to self-medicate. Only senior staff give out medications and have recently had a course of training in the home provided by Hull College. Residents spoke highly of the care they received and that they were treated with respect and their privacy maintained. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 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): 12,13,14 and 15 Until the new activities co-ordinator commences employment in the home, it has not always been possible for staff to provide activities which satisfies all the residents recreational interests. Contact with families and friends is flexible and promoted well within the home. Residents are encouraged to maintain their independence through being given choice and control over their lives. Meals are nutritious and offer a healthy and varied diet for residents. EVIDENCE: The home has been without an activities co-ordinator for some weeks due to the newly appointed person commencing work in the home being delayed for personal reasons. A care assistant continues to be employed separately every Thursday to take residents on trips out or to hold a baking session when residents who are interested make small cakes, scones and tarts for their own consumption. One resident enthused about the crosswords, painting, playing dominoes and visits to the Norland pub to play bingo. Mention was also made of being able to maintain independence and make choices with regard to daily living. Both residents and staff confirmed family and friends are able to visit at any reasonable time and the time can be spent with them either in the communal areas of the home or in their own room. The church visits the home and provides a monthly communion service and visits to the church are made Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 13 for special events and festivals eg Christmas and Easter. One resident makes a shopping list and the manager takes her into Hessle to obtain her purchases. Four weeks menus were seen to provide a Continental breakfast, fruit juice, main course and sweet at lunch, and three choices for tea with a sweet. Standard options of poached egg, omelette and cooked sliced meat are always available at lunchtime. The cook visits all residents the day before to identify their choice for the next day. One resident who does not like mince said she was having eggs for lunch as cottage pie was on the menu and she prefers eggs. Hot and cold drinks and snacks are provided throughout the day and on request. Set meal times are the norm, but if a resident wishes to eat outside the set times, then arrangements are made to meet their request. Specialist advice with regard to diets is obtained from the general practitioner and community dietitian. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints system with evidence that residents feel their views are listened to and acted upon. Vulnerable adults policies, procedures and staff training ensure residents are protected from abuse. EVIDENCE: Since the time of the last inspection, during November 2004, nine complaints have been recorded, all of which were satisfactorily investigated and resolved. Apart from one new member of staff, all care staff have had up-to-date awareness training for the protection of vulnerable adults. The manager and deputy manager have also attended the social services training for managers with updated training the week before this inspection. Guidelines for the multi-agency policy, procedure and practice for the protection of vulnerable adults are included in individual handbooks given to staff. A safe provides secure storage of residents’ monies and valuables held by the home on their behalf. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 15 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): 19,24,25 and 26 The standard of the décor within this home is generally good with evidence of ongoing improvements through maintenance and forward planning. The home therefore presents as a homely, comfortable and safe environment for residents to live. However, despite the best efforts of the home three bedrooms had an unpleasant odour. EVIDENCE: Woodleigh Manor is set in grounds which are accessible to residents, and the location and lay-out of the home is suitable for its stated purpose. The building complies with the requirements of the local fire service and environmental health department. Considerable improvements have been made to the home during the last two years eg tasteful redecoration in keeping with the home has taken place in all communal areas and some bedrooms, the hall, stairs, landing, lounges and some bedrooms have new carpets, the dining room and quiet lounge has new flooring and radiator guards have been fitted throughout the home apart from bedroom 12 which appears to have been Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 16 overlooked. The occupant of this room has not had a risk assessment although the bed end is placed alongside the radiator. Most bedrooms have been highly personalised with the resident’s own furniture, photographs and memorabilia, a number have their own telephone installed. Two bedrooms were not inspected at the time of this inspection as the rooms were locked, the resident having their own key. The environmental health officer inspected the kitchen and the cook stated apart from the seal around the sink needing replacing no other requirements were made; the home has not yet received the report. The home was clean and pleasant apart from three bedrooms which, despite the best efforts of the home, had an unpleasant odour; one of these rooms also had a soiled carpet. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 17 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 and 30 Sufficient staff are deployed at all times to meet the needs of the residents. Staff personal records were not inspected as the manager was on leave and they were locked away. An ongoing training programme ensures staff are well trained and competent to do their jobs. EVIDENCE: Thirty residents were living in the home at the time of this inspection. The staff rota indicated five staff employed on the early shift, three the late shift and two at night with someone on call; extra staff are employed to allow for staff training. The manager works supernumary. Four agency staff have been employed on day shifts over the last eight weeks and as far as possible, the same staff attend. All care staff are aged over 18 years of age and anyone in charge of a shift is aged over 21. Two new members of staff have been employed since the last inspection, but staff records were not available due to being locked away and the manager being on leave. Training is high on the home’s agenda and is identified during supervision. Recent training has included the community psychiatric nurse on understanding dementia, team leaders have had training from the district nurse on a special feeding technique needed for one resident, health and safety, Hull College have been providing a course of medication training in the home for the manager, deputy manager and team leaders and infection control for all staff. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 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): 33,35,37 and 38 The home is run in an accountable manner where staff are directed clearly. Routines of the home are based around needs of residents. Residents views are sought from time to time on a one to one basis but there is little evidence of the outcomes. Residents financial interests are safeguarded. Safety certificates were not seen at this inspection due to the manager being on leave. EVIDENCE: The home has parts one and two of the local authority quality development scheme and this is currently being reviewed for renewal. The Investors in People award has recently been reviewed and renewed for a further three years. The registered provider has not provided a report to the Commission on his visits to the home since June 2005 although the minutes of a staff meeting held in July mention the proprietor is making spot and staff, residents and visitors were reported as being happy with the services provided. Residents Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 19 meetings which were chaired by one of the residents has now ceased although the resident was unable to explain the reason for this. The deputy manager stated residents views are obtained on a more informal one to one basis but there is no evidence of how this changes anything in the home. Monies kept by the home on behalf of two residents was checked and found to be correct. Fire alarm and emergency lighting checks are recorded as taking place weekly. Two new members of staff interviewed had not had fire safety training. The health and safety notice displayed in the manager’s office is obscured by filing cabinets. Safety certificates for examination of the lift and lifting equipment and for gas safety were not available as the manager was on leave at the time of the inspection. Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 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 3 x 3 x x N/A 3 x x x x 2 2 2 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 1 x 3 x 3 3 Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 21 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 2 3 Standard OP7 OP9 OP9 Regulation 15 13 13 Requirement Ensure care plans are updated to reflect changing needs at all times Ensure the medication system is such that records are kept in good order at all times Ensure that medications are only stored in the home for those residents living there on receipt of this report and ongoing Ensure residents who are self medicating have appropriate lockable storage and have had a risk assessment Ensure the home is kept free of offensive odours at all times The registered provider must make unannounced visits to the home every month and send a report to the Commission (Previous timescale met, but this requirement has lapsed again) Timescale for action 31/10/05 31/10/05 30/09/05 4 OP9 13 31/10/15 5 6 OP26 OP33 16 26 30/09/05 31/10/04 Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 22 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 OP31 OP25OP24 Good Practice Recommendations The manager should work towards obtaining NVQ IV in care by the end of 2005 Ensure the radiator in bedroom 12 is guarded and in the interim the resident has a risk assessment Woodleigh Manor DS0000019776.V249991.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Manor DS0000019776.V249991.R01.S.doc Version 5.0 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. 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