Inspection on 12/07/06 for Woodley Day Centre - Short Break of Care

This inspection was carried out on 12th July 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

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

CARE HOMES FOR OLDER PEOPLE Woodley Day Centre - Short Break of Care Southlake Crescent Woodley Reading Berks RG5 3QW Lead Inspector Susan Cledwyn-Davies Unannounced Inspection 12 and 13 July 2006 19:00 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 Woodley Day Centre - Short Break of Care DS0000064776.V295218.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. Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodley Day Centre - Short Break of Care Address Southlake Crescent Woodley Reading Berks RG5 3QW 0118 9691471 0118 969 3412 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) Woodley Age Concern Mrs Ann Parr Care Home 2 Category(ies) of Dementia - over 65 years of age (2) registration, with number of places Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection N/A Brief Description of the Service: Woodley Short Stay service is based in Woodley Day Centre. There are two bedrooms with a bathroom and toilet. Short stay service users have use of the day centre facilities during the evening and early morning. As well as large lounges and a kitchen area there is an enclosed garden. Woodley Day centre for people with dementia both specialist day care and a short stay resource. The centre is in a residential area. There are minibuses permanently based in the centre and can be used by staff. All service users attending during the week up to this point have attended the day centre during the day. The current scale of charges are £185-£200 for two days care and overnight respite. (Less if two share.) Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in two parts, firstly 12th July between 7.10pm and 8.40pm to see a service user and staff member in the service and on 13th July to see records and discuss with the manager. A preinspection questionnaire was received from the manager. There was discussion with the staff member and contact with the service user. Records were seen plus further discussion the manager. What the service does well: 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. Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodley Day Centre - Short Break of Care DS0000064776.V295218.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 Woodley Day Centre - Short Break of Care DS0000064776.V295218.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, 2, 3 and 6 Good An outcome group judged as ‘Good’ has more strengths than areas for improvement. There are no significant weaknesses in areas relating to health and safety issues or management. The key NMS under this outcome heading are generally met but there may be some areas of improvement that we are confident the provider can manage. Where areas for improvement emerge the service recognises and manages them well. Information is given to service users and their carers. All potential service users are assessed prior to using the service. EVIDENCE: Service users and their carers are given the service users guide. All service users are assessed prior to using the service. This assessment has varied depending on how the service user started using the service. As there are three main services run from the Day centre, Day care, Short Stays and Domiciliary care then the Manager is aiming for the whole site to use the same pre-assessment form. Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 9 All service users have until now been attending the day centre prior to staying over with the short stay service. Therefore service users are familiar with the centre and with the staff. A record is kept of use of the short stay unit and staff accompanying. It is aimed to have staff and service user linked who have a positive relationship. Contracts are completed for use of the centre and include following the care plan. At present this contract is completed for each stay. This is being amended so that the contract remains valid according to the care plan. The care plan and changes will be shared with the carer. There is no intermediate care offered in this service. Woodley Day Centre - Short Break of Care DS0000064776.V295218.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 Good An outcome group judged as ‘Good’ has more strengths than areas for improvement. There are no significant weaknesses in areas relating to health and safety issues or management. The key NMS under this outcome heading are generally met but there may be some areas of improvement that we are confident the provider can manage. Where areas for improvement emerge the service recognises and manages them well. Service users care is planned and individual. Records demonstrated that individual needs are considered. Carers are involved and very happy with the service. The centre must ensure that risk assessments are completed for physical tasks and that daily records reflect all care given. Medication is safely administered. Training to ensure that staff administer according to policy should be recorded. Guidance on side effects of medication given would be helpful. Care staff provide individual care respecting service users wishes. EVIDENCE: Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 11 Each service user has a plan of care. This plan includes details of individual routines and likes and dislikes. The carer to help staff maintain the normal routine provides a record of the normal daily routine. Daily records are kept but could be expanded. The centre puts a lot of effort into providing high levels of staffing and highly personalised care to help maintain skills of daily living. The daily records should reflect the effort made. Within care plans were daily routines from carers so that service users normal routine could be followed. Staff advised that this is what happens. Carers via letters to the service said how pleased they were with the care given. Care plans need to have risk assessments that clearly say the risk when being mobile or having baths and details any individual care needed to ensure that service users have the right care. Consideration is given as to the bath to use and when this should be done. No baths are completed without other staff in the building. Annual reviews are being planned. A proposal is being prepared to put to the management committee. The carers arrange Service users health needs through local surgeries. The centre is involved if a service user becomes unwell and has the necessary contact telephone numbers. Medication is stored in the specialist unit and within a locking cupboard. Medication records were well maintained. Staff had medication training in the centre. One staff member was confident about the system and administered medication from original dispensed bottles dispensed by the pharmacist. Service users and carers bring medication to the centre. There was no knowledge of the side effects of common medication. It was suggested to the Manager that staff should be able to refer to a list of the side effects of the medication administered in the centre. The manager agreed to provide guidance. This is made a recommendation. Staff training in administering medication does not include observing them giving out medication and recording that their practice is safe. It is recommended that this take place. The short stay unit was visited in the evening when a service user was staying over. There was one member of care staff providing one to one care. The service user has poor verbal communication; her gestures and eye contact demonstrated she was involved and happy. Care staff were respectful and thoughtful. The care plan included a positive letter from relatives. Woodley Day Centre - Short Break of Care DS0000064776.V295218.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 Good An outcome group judged as ‘Good’ has more strengths than areas for improvement. There are no significant weaknesses in areas relating to health and safety issues or management. The key NMS under this outcome heading are generally met but there may be some areas of improvement that we are confident the provider can manage. Where areas for improvement emerge the service recognises and manages them well. Activities are varied and enjoyed by service users. Contact with carers is encouraged; carers confirmed attending the monthly meeting. Food is provided according to service users likes and includes fresh foods. EVIDENCE: Activities during the day are within the specialist day centre. During the evening individual activities take place according to the service user. This could be going out to the shops, using the centres minibuses, and returning to cook the meal with the shopping. On the evening of the visit the service user had eaten freshly prepared salad following the carers suggested normal meals. She was then having nail varnish applied and to bed following the usual home routine. As noted in the previous section daily records should reflect the individual care given including activities. Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 13 Contact with carers is very important. All carers are asked to give a normal day for their family member. Carers are supported by being encouraged to attend the monthly carers meeting for advice and support. This is also the opportunity for the manager to make sure that the service is satisfactory. Service users are encouraged to make choices and the evening and morning routine runs according to their needs and wishes. Meals are provided by the main kitchen during the day and in the evening and morning using the kitchen in the closed unit. The record of food eaten is kept in the daily record. A variety of fresh and prepared food was seen. Service users were seen during the day to eat and enjoy the food. Care staff receive food handling training. Woodley Day Centre - Short Break of Care DS0000064776.V295218.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 Good An outcome group judged as ‘Good’ has more strengths than areas for improvement. There are no significant weaknesses in areas relating to health and safety issues or management. The key NMS under this outcome heading are generally met but there may be some areas of improvement that we are confident the provider can manage. Where areas for improvement emerge the service recognises and manages them well. There is a positive approach to complaints and protection of vulnerable adults. EVIDENCE: There are no complaints about the service. There is a complaints procedure that is given to all service users and carers. Two letters of praise were seen in care plans during the inspection. The manager spoke of actively asking people if the service was satisfactory. No POVA concerns have been notified. The office has the multi-agency guidelines for investigating concerns. Some POVA training has taken place in house and staff are being entered for the local authority protection of vulnerable adults training as soon as possible. Care plans include POVA records of any bruising/concerns etc. Woodley Day Centre - Short Break of Care DS0000064776.V295218.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 Good An outcome group judged as ‘Good’ has more strengths than areas for improvement. There are no significant weaknesses in areas relating to health and safety issues or management. The key NMS under this outcome heading are generally met but there may be some areas of improvement that we are confident the provider can manage. Where areas for improvement emerge the service recognises and manages them well. The overnight accommodation is well furnished and decorated providing a comfortable place for service users. EVIDENCE: The short stay accommodation is in a wing of the day centre. Service users have full use of the centre with staff support. There are two bedrooms well furnished. The size of the rooms is slightly below 10sqm but these rooms are only designed for short stays. There is an assisted bathroom and laundry areas. Staff use the lounge next door to the bedrooms as the sleeping in room. The decoration and furnishings of the specialist centre are bright and cheerful as well as suitable for the service users. It is planned to provide a Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 16 larger bathroom with a choice of assisted bath or shower. The work is due to start shortly. There are laundry facilities with a sink, soap and towels for hand washing. The centre is checked monthly for any hazards. Woodley Day Centre - Short Break of Care DS0000064776.V295218.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 Adequate An outcome group judged as ‘Adequate’ has some strengths but areas of particular weaknesses that may require improvement through an improvement plan monitored by the Commission. Most Key NMS under this heading are almost met. We judge that residents are safe in how the service delivers this outcome area. Any risks highlighted are managed appropriately. Staffing levels are good except when a single member of staff is left alone in the evening. This is not good practice in case an incident occurs. Staff training in NVQ 2 is well achieved, initial training and further training is given. Staff recruitment is safe. The exceptions are obtaining a new CRB check for the Agency and keeping records of interviews. EVIDENCE: Service users needs are met by good staffing levels. If there are two service users there will be two members of staff. If there is one service user then there may be one care staff if the manager has judged that this is sufficient. The manager or another person will often be in the centre. In discussion it was noted that leaving one member of staff alone in the evening could be a risk in case an incident happened. During the night there is always an awake member of staff and a second member of staff sleeping in. The manager agreed that there would always be a second person in the building and would Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 18 confirm this with the management committee. A requirement is made about this. Of the bank staff used to staff this unit 2 have NVQ 2, a third has a nursing qualification and the last has none. Therefore over 50 of staff have NVQ 2 which fulfils the standard. Staff recruitment files were seen and included application forms, references and training records. Interviews take place but no records are kept of these; it is good practice to keep interview records. CRB checks from other organisations had been used but there is now no guarantee by the Criminal Record Bureau that checks can be transferred therefore new CRB checks are necessary. The Manager has just registered with an Umbrella Body to complete CRB checks for all staff. These checks should be completed before the carer provides individual care. If the manager decides to keep carers working then a risk assessment must be prepared. Initial training is given according to policies and procedures. POVA guidance has been given and a further POVA external course is arranged. Staff meetings are held in the whole centre. The first bank staff meeting for staff who give domiciliary care and short stay care is arranged for 25th July. Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 19 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 and 38 Good An outcome group judged as ‘Good’ has more strengths than areas for improvement. There are no significant weaknesses in areas relating to health and safety issues or management. The key NMS under this outcome heading are generally met but there may be some areas of improvement that we are confident the provider can manage. Where areas for improvement emerge the service recognises and manages them well. The manager is experienced and capable. Further management training is being commenced. Quality assurance questionnaires are being developed. Monthly meetings for carers already take place. Health and safety is well maintained. The exception is the need for a fire drill in the evening or at night and accident records need to be monitored. EVIDENCE: Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 20 The manager is experienced and capable. She is in the process of starting NVQ 4 training in January 2007. This training is made as a recommendation because firstly it is part of the National Minimum Standards and secondly good management is very important as the manager runs the day centre, the short stay unit and the domiciliary care service. The manager is planning to introduce quality assurance questionnaires on an annual basis. As the service users also attend the day centre the carers are part of the monthly meeting to support and help carers. This is an opportunity for the manager to discuss how the service is progressing. There were two letters from carers seen in care plans that were tracked. These letters were very complimentary about the care given. No finance is kept for service users in the short stay unit. Any money needed is invoiced to the carer. Supervision is being started in August. The manager has completed supervision training and has prepared a supervision contract to use for each staff. Supervision will then take place after this. Appraisals will be annual. Staff questionnaires confirmed that they are supported and their work observed. Maintenance of the building is the responsibility of Wokingham Council. The building is well maintained and records demonstrated this. The fire records included regular servicing of the system and fire equipment. Fire training takes place and fire drills during the day. There has not been a fire drill during the evening or night. This is required to make sure staff know how to react in an emergency. Accident records are kept. There is a building manager who is responsible for collating these records. These records are noted but not signed as monitored and action taken as necessary. It is recommended that records be signed. A regular report to providers for overview is suggested. A photocopy of the accident report is kept in each care plan. It was discussed that these are confidential and that the full report should be kept separately. The manager agreed and removed accident records. There is a hoist for staff use as necessary. Staff have been trained to use this. A senior carer in the centre has completed the training to be lifting and handling trainer for all staff. Training will take place soon. Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 21 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? 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 4 Standard OP7 Regulation 14 12 Schedule 3 18(1) 23(4) Requirement That written risk assessments are prepared for lifting and handling and other care tasks. That CRB checks are completed for all staff prior to starting work. That a minimum of two staff is on duty at any time. That a fire drill takes place during the evening or night. Timescale for action 01/09/06 01/09/06 01/08/06 01/09/06 OP29 OP27 OP38 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 4 5 Refer to Standard OP9 OP9 OP31 OP36 OP38 Good Practice Recommendations That all staff as part of medication training are observed administering medication and a record kept of this. That guidance on the side effects of medication is available. That the manager completes NVQ 4 in management. That supervision for all staff takes place. That accident records should be monitored. Woodley Day Centre - Short Break of Care DS0000064776.V295218.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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. 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