Inspection on 31/08/06 for Woodleigh Manor

This inspection was carried out on 31st August 2006.

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 Manor 13/08/07

Woodleigh Manor 13/02/06

Woodleigh Manor 19/09/05

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 Ann Day Unannounced Inspection 31/08/06 11:20 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.V296189.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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.V296189.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 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. Fees: £328.80- £360 Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included preparation, collation of information received, a pre inspection questionnaire completed by the providers of this service and fieldwork. The fieldwork included a tour of the premises; case tracking individual residents, noting their experience of care provided; examination of documentation; meeting with residents, interviewing staff members and the registered manager Donna Taylor. The site visit to the home took place on 31st August 2006 and was unannounced. Fieldwork took a total of 6 hours to complete. What the service does well: Care records were found to be comprehensive, including risk assessments, and detailed care plans, which are evaluated and regular reviews of individual care needs, are documented. The home employs a full time activities coordinator, and there is a published varied programme of activities made available for residents to participate in. The way in which activities are provided by the home, and the way in which records are maintained, is to be commended. The activities coordinator facilitates regular residents meetings enabling residents to participate fully in decision- making. Relatives said, “ Food is excellent as is the entertainment and every care is taken with all concerned”. “My father enjoys all social activities in the home and the trips out”. The home is well decorated, maintained and has an ongoing programme of maintenance and improvement; the home is clean, comfortable and homely in appearance. The home’s approach to and achievements in staff training are to be commended. Relatives said, “The staff at Woodleigh Manor couldn’t be better, always so helpful and jolly”. The home is in receipt of three external quality assurance awards Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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 Manor DS0000019776.V296189.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: The home has a comprehensive Statement of Purpose and Service User Guide. The manager confirmed that individual contracts for the residents are kept at the organisation’s accounts department. Service users’ case files were examined which included pre admission assessments completed for every new resident, as required. The home does not provide intermediate care. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The consistent good practice regarding the planning and delivery of care means that all service users can be sure that their health and personal care needs will be fully met. EVIDENCE: Members of staff were able to explain how they ensured individual resident’s dignity and privacy whilst providing personal care. The interaction and rapport between members of staff and residents was seen to be very good. Service users said, “I think it’s very nice here, staff are very good to me, they are polite; never rude.” “ I am satisfied with the care.” Individual residents named and labelled clothing is 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. Three service users were case tracked, following the care needed and provided for these individual service users. Care records were found to be comprehensive, including risk assessments, detailed care plans, which are Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 Page 10 evaluated and regular reviews of individual care needs are documented. At the time of the visit no resident suffered with pressure area care problems and no bedrails were in use in the home. The home has Safe Handling of Medication procedures in place and safe practices are adhered to. The home uses a monitored dose system, for the administration of medication. The manager ensures that only appropriately trained members of staff administer medication. Medication Administration Record sheets were examined and were accurate apart from one omitted signature, which was brought to the attention of the manager. Medication administration is regularly audited and medication returns were appropriately recorded. Recommendations were made that individual Care records and Mar sheets to include a recent photograph of the individual service user to further aid identification and safe practice. A further recommendation was made that regular weight monitoring records are included in individual service users’ care records. Currently they are filed separately. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have a wide range of opportunities to participate in stimulating and motivating activities of their choice. Meals and mealtimes are not rushed and are an enjoyable, social occasion for all of the service users and the quality of the food provided is of a high standard. EVIDENCE: The home employs a full time activities coordinator, and there is a published varied programme of activities made available for residents to participate in. All activities are individually care planned and recorded; members of staff promote the continuation of regular visits, e.g. church; particularly where these visits or activities were established patterns before an individual’s admission to Woodleigh Manor. Photographic evidence of the provision is made available and shows which residents have taken the opportunity to join in . Relatives said, “ Food is excellent as is the entertainment and every care is taken with all concerned”. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 Page 12 “My father enjoys all social activities in the home and the trips out”. 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 they take pleasure in activities such as baking, bingo, quizzes, craftwork and many more pastimes. The activities coordinator 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. The activities coordinator facilitates regular residents meetings, enabling residents to participate fully in decision-making. The cook attends quarterly to discuss menus, food choices and any issues relating to the food provided. A mealtime was observed, and in spite of the dining room being unavailable because of refurbishments, residents were seen to thoroughly enjoy an appealing, well presented hot meal for lunch. Seven residents were taken out to a near by restaurant for a meal accompanied by the activities coordinator and returned very pleased with the meal they had received and the prospect of having a Christmas meal out at the same venue. The home encourages open visiting, observation and service users confirmed that family and friends are made welcome. A male carer on the staff team enables male residents to choose to have care provided by a carer of their own gender, increasing their choices. The home has a Key worker system in place that works well. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel safe and listened to. The formal processes for complaints and the protection of service users have been fully developed so that the home’s procedures are available, understood and consistently applied. EVIDENCE: The home has policies and procedures in place; service users, relatives and members of staff know to whom they speak if they have any concerns. Members of staff have attended adult protection awareness training, and are clear about their responsibilities, with regard to the reporting of any incident, occurrence or concern. The home had one adult protection investigation during May 2006, which was dealt with appropriately, adhering to the home’s own, and the local authority’s policy, procedures and guidelines. Day to day concerns expressed by residents or their relatives, are dealt with directly or are raised at the regular residents meetings. The home has received six written complaints since the last inspection. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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): 19,20,22,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The good condition of the décor and fixtures and fittings means that service users live in a safe, comfortable and convivial environment. EVIDENCE: A tour of the premises was undertaken, aids and adaptations are in place to promote residents independence. The home was very comfortable and homely in appearance. Residents eat in a convivial atmosphere. The home has an infection control policy in place; the home is clean and odour issues have been well addressed. Several rooms have had carpets replaced and one bedroom is having new permanent flooring. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 Page 15 The dining room’s floor was being replaced on the day of the visit, several window blinds and curtains have been replaced; in addition work was being undertaken to improve ventilation in the home’s laundry, and the kitchen and home’s office have been fitted with air conditioning since the last inspection. The rooms of those service users whose care was case tracked (individual experience of care provided was followed) showed individuals had been able to personalise their rooms, and they were satisfactorily clean and well presented. Service users felt their rooms were comfortable. Aids and equipment were provided in the home, all of these were of a satisfactory quality. The stock of general aids, were in a good condition. The hoists were serviced regularly, which ensures the safety of and minimises risk for people who use the service. The home’s maintenance book and a detailed continuing improvement were available for examination. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are fully met, by a competent and trained staff group. EVIDENCE: The manager, and four members of staff were interviewed. All three staff files, induction training records and staff rosters examined were comprehensive and in good order. Staffing shortages are generally covered by the home’s own staff, ensuring continuity for the service users. The home uses agency staff from time to time to cover vacancies and sickness. The manager and staff confirmed that one agency is used and the staff supplied are regular and know the home and its service users well. Staff recruitment practices at the home are robust. Care workers confirmed that all the statutory checks had taken place before they started work at Woodleigh Manor. A relative said, “The staff at Woodleigh Manor couldn’t be better, always so helpful and jolly.” Members of staff interviewed were clear about their role, knew what was expected from them and showed a good understanding of the actions they needed to take to meet and promote independence, equality, diversity and choice. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 Page 17 The home employs a laundry assistant who ensures that all residents clothing is individually labelled; the laundry assistant’s role enables care staff to spend more of their time providing personal care. Members of staff confirmed that they are currently attending dementia care training. Staff said, ”Training is very good here”. “We work as a team.” Staff members and documentation confirmed that training, supervision and appraisal are regularly provided; and that several members of staff have successfully achieved NVQ Level 3 in care and a further number are currently undertaking NVQ Level 2. Currently 80 of the home’s care staff have achieved NVQ Level 2 or above. The home’s approach to and achievements in staff training are to be commended. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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): 31,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements are meeting the needs of the service, residents benefit from a safe and well managed place to live. EVIDENCE: Donna Taylor is an experienced manager, who has achieved NVQ Level 4, the Registered Managers’ Award and is registered with the Commission. The home’s three proprietors visit the home on a daily basis and the Commission has received copies of their reports. The proprietors are not distant from the home, they provide on call; a practical approach to addressing their obligation under Regulation 26 was discussed with Donna Taylor, the manager and Mr Phillip Jenkinson, the Responsible Individual. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 Page 19 A recommendation was made that a Regulation 26 report is written, signed by the proprietor when work is completed; copies of which are made available to representatives of the Commission. Members of staff confirmed that able service users use the postal voting system in elections. The home does not keep any service users’ personal monies. Service users are provided with locked storage in their own rooms keep valuables safely. Service users representatives are invoiced directly for the services of the hairdresser and chiropodist. Those unable to manage their own finances and who are also without family employ legal representation. Members of staff are regular formally supervised and are in receipt of annual appraisals. Staff said that they found the supervision and regular staff meetings useful, they said they were able to raise any concerns and that the manager , the assistant manager and the proprietors were all supportive and approachable. The home undertakes a number of internal audits and the organisation facilitates the use of cross audit with Woodleigh Manor’s sister home. The activities coordinator facilitates a regular residents’ meeting and a music night to which relatives are invited; the manager attends both functions, and is available to answer questions and feedback on progress on items/concerns raised. The home is in receipt of three external quality awards. Fire risk assessments and improved signage were in place. The manager is looking to source covers for the fire extinguishers in the home, to minimise damage and improve safety for those service users who are confused and restless. All service documentation was available for examination and up to date, as per regulations. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 3 Refer to Standard OP7 OP7 OP9 OP33 OP37 Good Practice Recommendations Care records to include a recent photograph of the individual service user to further aid identification. Regular weight monitoring records are included in individual service users care records. MAR sheets to include a recent photograph of the individual service user to further aid identification. That a Reg. 26 report is written, when work is completed by the proprietor, who visits daily; copies of which are made available to representatives of the Commission. Woodleigh Manor DS0000019776.V296189.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 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.V296189.R01.S.doc Version 5.2 Page 23 - 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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