Inspection on 18/09/07 for Woodley Grange

This inspection was carried out on 18th September 2007.

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

Woodley Grange 19/12/06

Woodley Grange 21/11/05

Woodley Grange 10/06/05

Woodley Grange 21/12/04

Woodley Grange 13/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Woodley Grange Winchester Hill Romsey Hampshire SO51 7NU Lead Inspector Peter J McNeillie Unannounced Inspection 18th September 2007 09:00 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 Grange DS0000011795.V344882.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 Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodley Grange Address Winchester Hill Romsey Hampshire SO51 7NU 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) 01794 523100 woodleygrange@lovingcare-mattus.co.uk www.lovingcare-matters.co.uk Manucourt Limited Andrea Hardy Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36) of places Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2006 Brief Description of the Service: Woodley Grange is a large detached property situated in a quiet residential area close to local amenities in the South Hampshire town of Romsey, with close links to the M27 and M3. It is close to a local bus route into Romsey and Winchester and rail links to Southampton. The home is registered to provide care to thirty six residents in the categories of old age, not falling within any other category and dementia, over sixty five years of age accomodated in eighteen single and nine double rooms on two floors. There are two large lounge/ dining areas opening onto a conservatory which overlook the homes well maintained safe and fully enclosed grounds. Fees at the time of this inspection were £400 to £ 525 per week. Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced visit was the first inspection for the years 2007/08 and took place on 18/09/07 between the hours of 09.00 am and 1.30 pm during which all of the key standards for care homes for older persons were assessed. A number of sources of information/evidence were considered in producing this report including a visit to the home, notifications to the Commission for Social Care Inspection (C.S.C.I.) under regulation 37, examining residents assessments/care plans, staff recruitment/ training records, policies / procedures comments by management, staff, residents, visiting health care professionals, residents relatives, the results of an in house residents satisfaction survey, information provided by the manager in a statutory Annual Quality Assurance Assessment (A.Q.A.A) and responses by residents, residents relatives and health/social care professionals to a pre inspection satisfaction survey carried out by C.S.C.I. The results/findings contained in this report will determine the frequency and type of future inspections What the service does well: What has improved since the last inspection? What they could do better: Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 6 No areas of concern were noted during this inspection however, there is a need to expand the current in house quality monitoring system to include formal responses from visiting health and social care professionals and the produce menus in a format that can be understood by all residents. 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. The summary of this inspection report can be made available in other formats on request. Woodley Grange DS0000011795.V344882.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 Grange DS0000011795.V344882.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of assessing and identifying residents needs which ensures their safety and assessed needs can be met. EVIDENCE: Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 9 Samples of three resident’s pre admission assessments were viewed. These confirmed that residents were only admitted after a detailed assessment of their needs and risk by a member of the homes management team had being carried out. Comments by residents and records viewed confirmed residents had been consulted and contributed to their assessments. Records also confirmed assessments of need and risk for all residents are reviewed on a regular basis and care plans (Section 7-11 of this report refers) adjusted if required. Intermediate care is not available in the home. Woodley Grange DS0000011795.V344882.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The arrangements for planning care are clear ensuring that the health, personal care and medication needs of residents are met and their privacy and rights respected. EVIDENCE: A sample of three residents care plans/records were viewed and a number of residents spoken to individually or in groups. All of the residents spoken with confirmed they were very happy, contented, liked the staff and management, were treated with respect felt wanted and would recommend the home to anyone. Residents responses to our questions relating to how they were cared for and living in the home were all very positive and included comments such as “ Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 11 Better than a hotel”,” I am more than happy”,” Well satisfied”,” Care is very good”. These comments were also mirrored in the in house and the Commission’s satisfaction surveys. During our visit we observed staff knock on bedroom doors and wait before entering and treat residents with respect, and dignity. All of the care plans viewed, (which were based on pre admission assessments of need and risk) were reviewed monthly, updated to reflect changing needs and included confirmation that residents were consulted about and participated in the production of the plan. As part of the care planning process the home/staff had invested a great deal of time, effort and expertise into producing very detailed life histories of the residents. This had also been reproduced in a pictorial format including photographs to aid the understanding of residents with dementia. Staff confirmed they found this addition to the care plans of great value when talking to and understanding residents and their needs. Residents spoken with confirmed they were able to see the doctor or any other health/social care professional of their choice when they needed to. Residents currently have a choice of up to twenty doctors from three local practices this allows for residents to consult a doctor of the same gender as themselves if they wish. During the visit the inspector spoke with a visiting health care professional that confirmed good communication between the home and herself/ her colleagues, a well-organised and knowledgeable staff who were well briefed on individual residents needs and a manager who was available and approachable. Records were kept of appointments with GPs, dentist, optician, chiropodist and any other external health/social care professional and included details of an advice/treatment given by them. Medication records seen confirmed that all prescribed drugs and medicines, which are securely stored, are dispensed by a pharmacist and administered by trained staff. The record of drugs and medicines administered to residents and unwanted drugs disposed of were complete and accurate. Records viewed confirmed regular audits by the manager of all drug/medicines related matters were undertaken. A procedure that ensures residents who wish may assume responsibility for their own medication was in place. Records indicated following a risk assessment no residents were responsible for there own medication. Woodley Grange DS0000011795.V344882.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social activities, family contacts and the provision of varied and nutritious meals were well managed and reflected service users interests and choices. EVIDENCE: A selection of recreational activities was available to residents. Current activities on offer include, quizzes, scrabble, cards, keep fit, dancing, games as well as visiting entertainers and occasional trips out to the local shops, town, pub and restaurants. Residents confirmed there was plenty to do and that participation was up to the individual, no one was forced to join in. The home has regular visits from local Church of England clergy who conduct services/communion in the home. Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 13 The needs of members from any other Christian denominations or other faiths can be catered for but at the time of this visit no members from other faiths were residing in the home. Residents confirmed they were fully consulted and were able to exercise choice in all aspects of their lives for example; when to get up and go to bed, mealtimes and where meals are taken, visiting times and the right to receive and converse with visitors in private. Residents also confirmed visitors were welcome at any time and that they were able to maintain links with the local community. Visiting relatives informed us they could come and go when they wished allways felt welcome and were kept up to date with any matters that concerned their relative providing the resident concerned agreed to the information being shared. The quality, quantity, presentation and choice of food served came in for particular praise from the residents. A written daily menu based on resident’s likes and dislikes was displayed. The inspector highlighted the need to ensure that the menu was displayed in format that all residents would understand. This is of prime importance for persons with dementia who may find the addition of pictures would be beneficial to understanding the daily menu and when making choices. The manager gave a verbal undertaking she would look into the way menus were displayed in future. Vegetarian options are always available. Persons on special diets religious or medical can also be catered for following individual written nutritional assessments, which are carried out, on all residents. We joined residents for their mid day meal that was conducted in a relaxed unhurried manner with staff available to give any resident assistance should they require it. We can confirm the quality, choice and excellent presentation of the meal during our visit. Tea and coffee making facilities were available to all residents and visitors at all times. Woodley Grange DS0000011795.V344882.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear policies and procedures in place which ensures residents are protected from abuse. The complaints procedure was satisfactory with evidence that residents feel their views will be acted upon. EVIDENCE: An in house Adult Protection policy/procedure that operates in tandem with the policy and procedure produced by Hampshire County Council designed to protect vulnerable residents from abuse was available as were records to confirm all staff had received training. Records viewed and staff spoken with confirmed they had received training in recognising abuse. All were able to demonstrate they knew what to do should they witness or suspect the abuse of any resident. The homes complaints procedure which was also included in the service users guide and the brochure given to all residents on admission included information on how to contact The Commission for Social Care Inspection Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 15 (C.S.C.I) was seen as was a record of complaints. No complaints had been received by C.S.C.I. since the last inspection Residents spoken to said felt comfortable in raising any concerns they had with the homes management and confident any matters raised would be dealt with fairly and promptly. Staff also confirmed they felt confident in raising any matter/complaint with the homes management on behalf of a resident. The views expressed by residents were similar to those stated in responses in the in house satisfaction surveys viewed. Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home is provided for residents which meets their needs. EVIDENCE: All areas of the home were clean and free from unpleasant odours and obvious hazards. Furniture was comfortable, homely and met residents needs. Residents and visiting relatives spoken with confirmed the home is always clean, smells fresh. Previous reports have commented, “ At present the laundry is too small. There is room for the machines, but no room to arrange laundry or iron. This room Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 17 becomes very hot, despite efforts to provide ventilation. This situation remains the same. No requirements are being made on this occasion due to the imminent building works that are being undertaken. As part of the future plan, planning permission has been obtained to build an additional wing, which will contain twenty-three new bedrooms all with en suite facilities plus a lounge and kitchenette for residents. Additional space will also be available for offices and staff training suite. Plans also include a complete refurbishment of the existing building, which include the provision of a new kitchen, lounge, overcoming the problems that exist with the current laundry and converting some of the existing double rooms into single rooms with ensuite facilities. We were informed building work would commence in March or April 2008. When all building work is complete it is envisaged a dedicated wing within the home will offer accommodation specialist care and support for persons with dementia who should have access to a secure landscaped garden area. Since the last inspection the dining room, lounge and conservatory have all been decorated and the kitchen refurbished and decorated. Bedrooms continue to be redecorated and re-furbished as part of a rolling improvement programme. Assessment to ensure that any equipment and personal aids required by residents are available has been carried out. Aids currently in use within the home include hoists (various) special chairs, raised toilets, ramps, chair lift, passenger lift beds walking frames and handrails. Security in the garden, which has been improved by additional fencing, is a real asset providing a pleasant area to look at and relax in. Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all residents. EVIDENCE: At the time of the inspection the four care staff on duty were supported by a number of other personnel including, the registered manager, two cleaners, a gardener, a laundry assistant, a handy man, a cook and a kitchen assistant. Residents confirmed the number of staff available ensured help was always prompt, efficient and carried in a pleasant and discreet manner. Care staff commented they had ample time to carry out their tasks. Two waking care staff supported by one sleeping staff were available at night. Staffing levels are frequently reviewed and adjusted to ensure the assessed needs of residents are met at all times especially in the morning when at least six staff are available. Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 19 Since the last inspection the home has, following a final assessment granted “Investors in People” status/ award. As part of their terms and conditions of employment, all staff agrees to undertake N.V.Q training courses which they start following a “ Skills for care induction/foundation course. Training /refresher coursed on additional subjects such as the administration of medication, food hygiene, infection control moving/handling, dementia, protecting persons from abuse and first aid are also undertaken. Staff spoken to stated how much they enjoyed working in the home and the opportunity to participate in training. At the time of the inspection 50 of staff had been trained to N.V.Q level 2 with a further 18 expected to complete their course within a few weeks of this visit. Considerable progress has been made in staff training which continues to be an area of high priority and constant review within the home using trade journals and the internet to ensure that current best practice guidelines and models are followed and adopted The staff group within the home is very stable many staff having worked in the home for many years, some more than twenty years. Records seen confirmed all staff are recruited in accordance with the home’s selection and recruitment procedure which includes the completion of an application form, an interview, signing a rehabilitation of offenders declaration and satisfactory Criminal Records Bureau (CRB), Protection of Vulnerable Adults (POVA), immigration, qualification and reference checks. Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home ensures the health, safety and welfare of residents and staff are promoted and the home is run in the best interests of the residents whose views about living in the home are formally sought. Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager who has been in post since August 2005 has had many years experience of managing residential homes for the elderly is qualified to N.V.Q. level 4 has also been awarded her registered managers award (N.V.Q. 4) since the last inspection. In talking with staff the we confirmed that the manager has established a well defined management structure including the appointment of a Head of Care and agreed aims and objectives for the home in consultation with the staff who have a clear understanding of what needs to be done and how to do it. The past two years have been a period of improvement and steady progress within the home as demonstrated by the results of this and previous reports. Progress includes the implementation of a formal quality monitoring system that seeks the views of residents and their relatives/representatives but needs to be expanded to include visiting social/health care professionals. Monthly visits that are required to be undertaken by a representative of the organisation in accordance with regulation 26 and the production of subsequent reports to are taking place. A sample audit was taken of residents monies held for safekeeping. All cash held reconciled with the records that included receipts of all money spent. A corporate health and safety policy was in place to ensure the day-to-day safety of staff and residents. Procedures include, weekly health/ safety checks, the regular servicing of equipment, staff training in the techniques of moving and handling infection control, control of substances hazardous to health (C.O.S.H.H.) first aid, health and safety, reporting accidents and procedures to follow in the event of fire (including evacuation). All of the hot water supplies to baths were fitted with thermostatic controls are set at 43 degrees centigrade and all radiators and hot pipes covered. Records seen confirmed all staff had received regular supervision. Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 22 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 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 23 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. 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. Refer to Standard Good Practice Recommendations Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Woodley Grange DS0000011795.V344882.R01.S.doc Version 5.2 Page 25 - 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!