Inspection on 13/09/06 for Woodleigh Rest Home

This inspection was carried out on 13th September 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 Rest Home 28/02/06

Woodleigh Rest Home 18/01/05

Woodleigh Rest Home 28/09/04

Woodleigh Rest Home 09/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Woodleigh Rest Home Woodleigh Rest Home Brewery Lane Queensbury Bradford West Yorkshire BD13 2SR Lead Inspector Sughra Nazir Unannounced Inspection 13th September 2006 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 Rest Home DS0000001251.V307588.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 Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodleigh Rest Home Address Woodleigh Rest Home Brewery Lane Queensbury Bradford West Yorkshire BD13 2SR 01274 880649 01274 880649 Telephone number Fax number Email address N/aProvider 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) N/a Mr Gerald Tyler Care Home 33 Category(ies) of Dementia (11), Old age, not falling within any registration, with number other category (33), Physical disability over 65 of places years of age (11) Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Woodleigh is a care home situated in the Queensbury area of Bradford. The home does not provide nursing care. The property has been adapted and extended to provide personal care only for 33 elderly male and female residents both in single and double rooms on the ground and first floors. The rear entrance provides disabled access to the ground floor with a stair lift enabling access to the first floor. There are two lounges and one dining room on the ground floor. Fees range from £318.00 to £354.75 per week. Respite stay rates are either £45.43 per day or £50.68 per day dependant on the level of need. A copy of the last inspection report, Service user guide and Statement of purpose are all prominently displayed in the reception area of the home. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) will be inspecting homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between April 2006 and June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All the key National Minimum Standards are assessed and evidence gathered is used to assess outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific areas and are known as random inspections. This was the first key inspection of this home for the 2006 to 2007 period. Due to the number and nature of requirements outstanding from previous inspections the indicative quality rating for this home was adequate. There is no registered manager in post. The staff member who was acting up into this role does not want apply for the position. A permanent replacement is being sought. For most of the inspection the owner was present. The visit to the home was carried out by one inspector who took 8 hours to gather information by looking at files and speaking to the residents, the owner and staff before giving the owner detailed feedback. Vicki Clark, Learning and development manager from the Commission who shadowed the site visit also reviewed some of the documentation. Prior to the visit a pre-inspection questionnaire was sent out to the owner for completion. This was not returned, however the owner provided comprehensive information covering a range of standards. This information was very helpful and has been used as evidence to support the visit findings. Surveys were sent to the home for completion by residents and relatives. To date, ten responses have been received from relatives or visitors. Ten survey forms have also been received from residents. Any comments made in the surveys or during the site visit are included in the report. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Considerable work is needed to implement the new care plan format. Care plans must include uptodate information and risk assessments about residents. This will mean care needs are not overlooked. Health needs must be assessed and documented. Mealtimes must be structured and organised to ensure that service users get the assistance they need. The home must ensure that work to meet fire safety regulations is completed. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 7 A manager must be appointed as soon as possible and application made for registration with the Commission. The home must ensure that all care staff offer good and consistent levels of support at all times. Minimum requirements for supervision must be implemented. 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 Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 8 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 Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 9 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 The quality in this outcome area is good. This judgement has been based on available evidence including a visit to this service. Current and prospective residents have the information they need to decide whether the home can meet their needs. The home does not provide intermediate care. EVIDENCE: The statement of purpose is contained within a very comprehensive document that gives current and prospective residents all the information they need about the home. The document is regularly updated with staffing changes, improvements to the environment and copies of the newsletter. This is good practice. There are detailed pre-admission procedures. The home carries out an assessment to determine whether it can meet a person’s needs. The owner provided an example where the home was currently working with family members to secure an alternative placement as a resident’s needs had changed and could no longer be accommodated. The home does not provide intermediate care. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 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 The quality in this outcome area is poor. This judgement has been based on available evidence including a visit to this service. Staff do not have all the information they need to meet residents’ needs. There is a risk that needs could be overlooked or unmet. EVIDENCE: The owner has developed a new care plan system. The new format will make information easier to complete and find. A number of care plans in both the old and new formats were looked at. In all cases the care planning documentation needed updating. One care plan contained a care plan agreement that was signed and dated. The date of admission was recorded, as were next of kin details. However, the care plan was last reviewed on 17th January 2005. There was a record of falls but the resident was not identified as being at risk of falls in a falls risk assessment on file. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 11 One resident appeared to have strong preferences in relation to clothing they wore that fitted their own lifestyle. There was no reference to this in their care plan. Another resident’s file stated that they had epilepsy on admission. This was not mentioned in either the assessment or in a care plan. The same resident had lost half a stone but there was no record of staff seeking further support. The owner said that in such instances weights would be taken and recorded weekly and support sought from GP or dietician. Such actions must be recorded. All care plans must be updated. They must be based on recent assessments of needs and give carers the information they need to meet residents’ needs. Any risks must be identified. Monthly weights are now being recorded. A member of staff informed the inspector that one resident has an infectious disease however there was no recording or documentation to suggest that diagnosis was confirmed or that advice had been obtained from relevant health professionals. The owner advises that appropriate care and steps are being taken but the record-keeping needs to improve to reflect this. A new form has been developed for district nurse visits. This records date of visits, residents’ treated and further advice given. This is an improvement on previous systems however it was discussed that separate recording for each individual would allow confidentiality to be maintained. Residents said that staff usually knock before entering bedrooms. They can receive visitors in the privacy of their own rooms. Medication records were examined and found to be complete. Improvements have been made to the way medication is ordered and recorded within the home. All staff administering medication have had training to do so. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 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 The quality in this outcome area is adequate. This judgement has been based on available evidence including a visit to this service. The range of activities is improving. Residents have access to healthy and varied meals but support available needs improvement. EVIDENCE: The home has appointed an Activities coordinator and work has started on developing individual activities care plans. On the day of the inspection visit several residents went out for the afternoon. Information provided by the home prior to the inspection states that • residents are entertained by an outside singer or performer once a fortnight • there was an in-house variety production in June with staff and friends taking part in the “Woodleigh Follies” • shopping trips by taxi are arranged for two residents • clothes sales are arranged three or 4 times a year • there are plans to provide widescreen tv, video and dvd facility for film nights and install a stage area as part of the dining room refurbishment • relatives events take place at Easter, Bonfire night Christmas etc Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 13 Residents have access to hairdresser visits weekly. There is a sweet trolley with confectionary and toiletries that is operated on a Friday and is wellreceived by residents. A new catering manager/chef appointed who has attended residents’ meetings. A questionnaire/survey of residents has also taken place to identify food likes and dislikes. As a result of this consultation mealtimes have changed as a result. There are plans in place to update and modernise the dining room the owner said that this will include replacing crockery etc The serving of lunch was observed. This was a three course meal with soup to start. Staff started to carry meals from the kitchen into the dining room on trays. Only one member of staff was then available to carry on. There appeared to be a lack of support from staff and some residents who needed assistance did not receive it. At times the support appeared erratic, some residents were eating their dessert whilst others had yet to receive their meals. One resident asked for tea twice and another resident asked on her behalf. Another resident said that sometimes staff forget to put teabags in the teapot. There were salt and pepper dispensers on the table but some of these needed cleaning out. No napkins or serviettes were provided and one resident used the tablecloth to wipe her hands. At least one meal was removed from the table uneaten without the resident being asked if they needed help or wanted an alternative. The owner said that most of the residents who need help with eating received their meals and assistance in the lounges. Attention must be paid to how lunchtime is structured and organised to ensure that everyone gets the help they need. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 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 quality in this outcome area is adequate. This judgement has been based on available evidence including a visit to this service. Residents have access to a clear complaints procedure and are protected from abuse. EVIDENCE: There is a complaints policy in place. This sets out timescales for response and is displayed in the main lounge. The owner responds personally to all complaints. Suggestions were made to improve the way in which complaints and subsequent responses are recorded. There is an adult protection policy in place and contact details for local social services are displayed There are plans in place for all staff to have training on the Protection of Vulnerable adults and this subject is covered in some detail on the induction course. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 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 and 26 The quality in this outcome area is adequate. This judgement has been based on available evidence including a visit to this service. Refurbishment is taking place. Cleaning services need to improve and work on fire safety needs to be completed. EVIDENCE: The standard of décor is good and bedrooms show a high degree of personalisation. Residents said they were free to bring in any personal possessions including furniture. The owner has contracted the services of a private company to undertake the majority of cleaning tasks in the home. On the day of the site visit the standards of cleanliness in the home were found to vary. Some bedrooms were found to be malodorous. The owner was asked to ensure the deep cleaning of chairs was undertaken as part of their agreed work programme. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 16 Following requirements made by the Environmental health officer – extensive work has been carried out in the kitchen. New equipment has been installed such as larger microwave extra fridge etc Work was in progress to install new fire doors upstairs. This is in advance of the regulations coming into effect on 1st October. A new stair-lift has been installed. Personal toiletries were seen in two bathrooms downstairs, the upstairs shower room had a net flannel left in the corner. This is not good practice in infection control and these matters were brought to the attention of the owner. Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 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, 28 29 and 30 The quality in this outcome area is adequate. This judgement has been based on available evidence including a visit to this service. Staffing levels are good and there is a strong commitment to training. EVIDENCE: There is a strong commitment to training from the owner of the home. There is a detailed training programme in place. NVQ (National Vocational Qualifications) levels were approaching 100 but the level has dropped due to a number of experienced carers leaving the home. Two new staff has recently been employed from abroad. A small number of staff files were looked at and found to be generally complete. Minor improvements were suggested. Woodleigh Rest Home DS0000001251.V307588.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, 32, 33, 35 36 and 38. The quality in this outcome area is adequate. This judgement has been based on available evidence including a visit to this service. Consultation and communication with residents and relatives is good. Day-to-day management and care staff supervision needs improvement to ensure that residents receive the care they need. EVIDENCE: There is no registered manager in post. A manager must be appointed and application made to the Commission for registration. The home’s newsletter provides good evidence of the ethos and philosophy of the home. News is shared about achievements, staff training, refurbishments etc Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 19 Staff and residents meetings take place regularly. There are plans to set up a committee that will involve relatives in decision-making. The Statement of purpose states that the home operates the Cared 4 quality management system. Surveys have been used recently in the home to identify food likes and dislikes, preferred mealtimes etc. As a result changes have been made to mealtimes and a revised menu is planned. Financial records are maintained. Feedback from some residents suggests that some care practice does not reflect the otherwise positive ethos and philosophy of the home. One resident said that the new staff members were both very willing to help and that some of the other staff often said “in a minute” when they asked for help. Another resident said that staff were not available at some times as they take their breaks together, One relative in their survey response said that “care is erratic- changes from week to week. Depends who is in charge and which staff are on duty. ” They also said that “staff do not always have time to sit and listen” One resident response said that they sometimes knew whom to contact if they were unhappy “if certain people are available.” One resident said that staff are sometimes available when they need them and commented that “ the staff work hard especially as more residents now have greater needs. Sometimes it is hard to find a carer. Ideally there should always be one available in the main areas, but often there isn’t e.g. If putting residents to bed. There is a culture of all the staff having breaks together, which means that at certain times, it’s difficult to get their attention. They also smoke in the communal eating area. “ From this feedback and observations it is evident that residents are not receiving a consistently good level of support from staff. This must be addressed. The owner currently conducts quarterly meetings with staff as appraisals and reviews training and development. Supervision must take place at least six times a year and include practice issues. There are detailed health and safety procedures and records in place. Woodleigh Rest Home DS0000001251.V307588.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 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 X 3 Woodleigh Rest Home DS0000001251.V307588.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. 1 Standard OP7 Regulation 15 Requirement The registered person must make sure that all residents care plans are brought up-to-date. They must provide an accurate record of the care needs and action needed. Risks must be assessed. Monthly reviews must be carried out. Health needs must be assessed and recorded. Mealtimes must be structured and organised to ensure that service users get the assistance they need. The registered person must ensure that the building complies fully with the fire safety report and requirements coming into effect on 1st October 2006. The registered person must ensure that service users health and welfare is maintained through clean and infection-free premises. A manager must be appointed and application made to the Commission for registration. The registered person must DS0000001251.V307588.R01.S.doc Timescale for action 31/12/06 2 3 OP8 OP15 12 12 31/12/06 30/11/06 4 OP19 23 31/12/06 5 OP26 12 31/12/06 6 7 OP31 OP36 39 12 31/12/06 31/12/06 Page 22 Woodleigh Rest Home Version 5.2 ensure that staff receive supervision at least 6 times a year and that this covers practice issues. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodleigh Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Rest Home DS0000001251.V307588.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!