This inspection was carried out on 28th February 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.
CARE HOMES FOR OLDER PEOPLE
Woodleigh Rest Home Woodleigh Rest Home Brewery Lane Queensbury Bradford West Yorkshire BD13 2SR Lead Inspector
Michael Smithson Unannounced Inspection 28th February 2006 10:00 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 Rest Home DS0000001251.V283460.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 Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 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 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) Mr Gerald Tyler Mrs Julia Chippendale 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.V283460.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th September 2005 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. Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the morning and early afternoon of the 28th February 2006. This was the second and final inspection for this year. The first inspection was undertaken in September 2005 and was announced. Copies of inspection reports for this and previous visits are available either from the home or on the CSCI website. The inspection focused on any requirements or recommendations made at the previous inspections, the environment and discussions with service users. The feedback from service users was positive. A visitor was also present for part of the inspection and again provided positive comments about the home. The registered manger is currently on maternity leave and the provider and the deputy manager are covering her responsibilities. What the service does well: What has improved since the last inspection?
Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 6 The lunchtime at the last inspection was slightly chaotic. There did not appear to be adequate staff to meet the needs of the service users. At this inspection the general organisation of the mealtime was much better and service users who required assistance had their needs met. The levels of NVQ level 2 training for the staff team has improved. If all staff currently undertaking the training complete they will exceed the required 50 in March 2006. 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 Rest Home DS0000001251.V283460.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 Rest Home DS0000001251.V283460.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): 3. The admission process is good and includes introductory visits and preadmission assessments. EVIDENCE: The records for 2 new service users were checked during the inspection. Both had pre-admission assessments included, which had been completed by the placing social workers. The information provided details of the needs and abilities of the service users. This allowed the staff to determine that the service user would be properly placed at the home. Woodleigh Rest Home DS0000001251.V283460.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 and 9. The health and personal care needs of service users are well recorded. The recording of medication must be improved. EVIDENCE: The care records for 3 service users were checked during the inspection. All had pre-admission assessments and care plans. The care plans had been regularly reviewed by the care staff. Risk assessments had been completed where risk has been identified. A spot check of the medication system was undertaken. The Nomad monitored dosage system is used at the home. The medication for a new admission was checked. The drugs had not yet been included in the monitored dosage system and were still held in the packaging. The drugs had been entered into the medication administration records. However the numbers of drugs contained and the date received was not included. This meant an accurate stock check could not be undertaken. Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 10 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. Woodleigh provides a good range of activities geared to both individuals and small groups. Service users are offered a good range of choices in their daily lives. EVIDENCE: Organised activities were not taking place on the morning of the inspection. However a range of activities are offered. The provider is looking at employing an activity organiser to further improve the range of activities offered. The inspector spoke to a number of service users who were in their bedrooms during the building inspection. Many of them organised their own activities which included reading books and newspapers and listening to music. The home has produced a newsletter, which is given to all service users and visitors. The newsletter contains information regarding, staff up dates, planned activities and outcomes of the service user meetings. Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 11 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): Not assessed at this inspection. EVIDENCE: Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 12 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, 21, 22, 23, 24, 25 and 26. The refurbishment plan for the building is still being implemented and improvements made. The stair lift reliability must be improved. EVIDENCE: A tour of the building was undertaken during the inspection. The home is currently being refurbished, however it is being completed while service users are still living at the home. The home provides bedrooms on the ground and first floor. Many of the bedrooms on the ground floor have been refurbished. The stairs and landing are currently being redecorated and a new carpet fitted. The communal areas consist of 2 lounges, a sun lounge and a large dinning room. The decoration was adequate. A new sluicing system has been purchased and the kitchen is due to be refurbished in the near future.
Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 13 The home has had problems with the stair lift linking the ground and first floor. At the time of the inspection it was broken resulting in a number of service users having to move down to the ground floor. The broken stair lift is awaiting a new part and should be repaired in the next few days. Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 14 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. A very good level of training has been provided to ensure staff had appropriate skills to meet their needs. EVIDENCE: A number of vacancies currently exist for senior care staff. The provider is hoping to recruit 2 overseas staff. The home continues to provide a good range of training for the staff team. A training plan has been produced and staff can request training using the individual supervision sessions. Good progress continues to be made with regard to the NVQ level 2 training for care staff. When all staff have completed the training they will achieve 60 NVQ level 2 qualified. The provider is hoping to advertise for an activity organiser, which would be an asset to the staff team. Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 15 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 and 36. The home is being fairly well managed while the registered manger is on maternity leave. However standards must be monitored to make sure they are maintained. EVIDENCE: The current registered manager is on maternity leave and is due back at the home in June 2006. The provider is playing a more active role in the day to day running of the home assisted by the deputy manager. The registered manager had made excellent progress in moving the home forward and improving the general standards of the home. Some comments were made from visiting health care professionals regarding the changes noticed since the registered manager had been away from the home. The issues were minor and they were happy to raise them with the provider. The provider is aware that the senior care staff needs to make sure that standards
Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 16 are maintained and has recently held a meeting with senior staff to re-affirm the standards expected. The provider has continued with the staff supervision programme. All care staff has had individual supervision, which includes looking at work performance and identifying trainings needs. Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 17 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 3 3 2 3 3 3 3 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 2 3 3 X X 3 X X Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 18 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 OP9 Regulation Reg 13(2) Requirement The drug administration records must include the numbers of medications brought in on admission and the date commenced. The stairlift must be repaired and maintained in good working order. The manager must achieve NVQ level 4. Timescale for action 01/04/06 2. 3. OP19 OP22 OP31 Reg 23(2)(c) Reg 9(2) 01/03/06 31/12/06 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 OP31 Good Practice Recommendations The provider should monitor staff performance to make sure that good standards are maintained. Woodleigh Rest Home DS0000001251.V283460.R01.S.doc Version 5.1 Page 19 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
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