Inspection on 21/11/05 for Woodley Grange

This inspection was carried out on 21st November 2005.

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 18/09/07

Woodley Grange 19/12/06

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 21st November 2005 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 Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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.V266661.R01.S.doc Version 5.0 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 sue@lovingcare-mattus.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.V266661.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection120:06;05 Brief Description of the Service: Woodley Grange is a privatley owned and managed care home set in its own large grounds situated in a quiet residential area close to local amenities in Romsey with close links to the M27 and M3 motorways, local bus routes into Romsey and Winchester and within easy reach of 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. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections for 2005/2006. During the inspection, which took place between 9:00am and 2:15pm the inspector who was assisted by the Registered Manager, spoke with 12 residents, staff on duty and visiting relatives. Evidence was also gathered from a tour of the building, reading records, care plans, previous inspection reports comments by management/staff, observations and responses to comment cards distributed prior to the inspection by The Commission for Social Care Inspection (C.S.C.I.),The managers written responses in a pre inspection questionnaire and a self assessment of the home/service.. During this inspection the inspector concentrated on those standards that were the subject of a requirement following the previous inspection (all of which had been complied with) and core standards not previously inspected this year. Two requirements were made following this inspection one relating to medication risk assessments and the second to providing a quality monitoring system that seeks service users views. Since the last inspection a new manager has been registered and been in post since August 2005. This appointment has had a considerable beneficial and positive affect within the home where the quality of the service has improved. What the service does well: What has improved since the last inspection? Since the last inspection the leadership supplied by the new registered manager in tandem with a well-motivated staff team have almost eliminated requirements. There is in the motivated staff team a sense of direction and purpose and a willingness to develop and improve the service for all of the residents. There are many areas of improvement assessments, care planning, the control of medication, staff supervision, security and the physical environment being the most noticeable. All those responsible (especially the Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 Page 6 manager) can feel proud of what has been achieved so far in such a short time. 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. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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.V266661.R01.S.doc Version 5.0 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 and 3. Prospective residents are issued with information they need to make a choice about living in the home which has a well developed system of assessing and identifying residents needs which ensures residents safety and assessed needs can be met. EVIDENCE: Residents confirmed they had all been made aware of and seen the homes statement of purpose prior to admission and issued with terms and conditions of residence and a service users guide on admission. The homes statement of purpose has been updated to reflect the recent changes in the management in the home. As part of a new business/action plan the new manager is in the process of reissuing to all residents a revised, expanded and updated service users guide. Progress will be evaluated in a future visit to the home. Residents and records confirmed the manager or other member of the senior staff and a number only admitted persons on the basis of a full and detailed assessment of need and risk, this process would also include consultation with Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 Page 9 external health care professionals and the potential resident or their representative, consultation was confirmed by records viewed and comments made by residents. Records viewed also confirmed assessments of need and risk for all current residents are reviewed on a regular basis again in consultation with a number of other external health care professionals including doctors, community nurses, community psychiatric nurses continence advisors, nutritionists, physiotherapists. Since her appointment as part of her programme of improvement the manager is reviewing all previous assessments of need and risk and producing them in a different format. Progress to date shows a great improvement on previous assessments/documentation. Further progress will be reviewed at a future visit to the home. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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 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: Following the last inspection a requirement was made relating to the quality of the care plans and the care planning system. Following a review a new format for the production of care plans has been adopted that has overcome all previous concerns. A sample of the care plans viewed indicated all plans were reviewed monthly. and based on based on multidisciplinary assessments of need (including special needs) and risk following consultations with residents/residents representatives. The manager as part of her business plan is reviewing the current format/system of care planning. Progress will be reviewed at a future visit to the home. Residents in confirming that staff addressed them in a polite manner in the way they wished always knocked before entering their room, expressed in glowing terms total satisfaction with the care they were receiving, the manner in which it was delivered.”A1”,”It’s lovely” ”no complaints” ”totally satisfied with mothers care” are typical of the comments made. The manager and the Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 Page 11 staff came in for particular praise, for their kindness , efficiency and willingness to help. Following the last inspection three requirements relating to a policy covering the covert administration of medicine, the accuracy of recording medicine administered and the training of staff responsible for administering medication were made. All previous requirements have been complied with. All resident’s drugs and medicines, which are securely stored, are administered in accordance with a medication policy and procedure including the covert administration of drugs and medication. Records viewed of medication administered or disposed were complete and accurate. One resident was selfmedicating. Written risk assessments and evidence to confirm consultations as who is responsible for the administration of resident’s drugs and medication were not available. Since the last inspection all staff administering drugs and medicines had received training from the home pharmacist when a new system of administration was adopted. The pharmacist is available to offer advice and support in all matter relating to drugs and medication. Staff confirmed residents or their representatives were free to choose their own GP and the source of other personal services e.g. chiropodists, dentists optician etc and would receive assistance in accessing any service in the community. Any restriction on choice with regard to a GP was outside the control of the resident or the homes management. Currently five local practices employing approximately twenty doctors visit the home. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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 and 15 Arrangements for family contacts and the provision of varied and nutritious meals were well managed and reflected service users choices. EVIDENCE: Residents confirmed visitors were welcome at any time and that they were able to maintain links with the local community. Visiting relatives confirmed they could come and go when they wished and allways felt welcome. The inspector was informed that should transport prove to be a problem, this could be provided by the home to ensure family contact was maintained. Residents confirmed they were fully consulted and were able to exercise choice in all aspects of their lives ie, when to get up and go to bed, mealtimes etc. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 Page 13 The quality, quantity, and choice of food served came in for particular praise from the residents. A written daily menu based on service users 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. The manager gave a verbal undertaking she would look into the way menus were displayed in future. Progress will be reviewed at a future visit to the home. Individual written nutritional assessments for all residents had been carried out. Special dietry needs are catered for. The inspector who joined the residents for there mid day meal confirms the quality, choice and excellent presentation of the meal. Tea and coffee making facilities were available to all residents and visitors at all times. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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 17 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: A corporate Hampshire County Council policy/procedure designed to protect vulnerable residents from abuse and records confirming all staff had received training in adult protection, were available. Staff spoken with confirmed and demonstrated they were aware of the procedure to follow should they witness or suspect the abuse of any resident. The complaints procedure, which was also included in the service users guide, provided information on how to contact The Commission for Social Care Inspection (C.S.C.I). A record of complaints was maintained. Residents spoken to stated they felt comfortable in raising any concerns they had with the home’s management and were confident any matters raised would be dealt with fairly and promptly. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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): 19,22, and 26 A safe, well maintained, clean and suitably furnished home is provided for service users which meets their needs EVIDENCE: A tour of the building indicated that in the main it was fit for its stated purpose, accessible, safe, well maintained and meeting resident’s individual and collective needs. 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 becomes very hot, despite efforts to provide ventilation. Laundry is, therefore, arranged for distribution in one of the main corridors of the home, which is not in keeping with the standard of the communal environment elsewhere in the home.” The inspector is due to meet with the homes providers to discuss a re- furbisment /extension at the home which should overcome this problem. In view of future changes a requirement Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 Page 16 is not being made on this occasion. This matter will be reviewed at a future visit to the home. Furniture was comfortable and homely and in keeping with the décor. Residents commented how satisfied they were with the accommodation. Since the last inspection three bedrooms have been re-furbished as part of a rolling improvement programme. As part of the future plans for the home it is anticipated all shared rooms will become single rooms fitted with ensuite facilities and new single rooms provided. Following the last inspection a requirement was made re monitoring temperatures in the lounge/conservatory areas. This requirement has been complied with. Assessment to ensure that any equipment and personal aids required are available have 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. The home, was, cleans, hygienic and free from adverse odours. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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. Residents needs are met by sufficient numbers of staff who are recruited and selected using a procedure designed to protect all service users. 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, 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. Since the last inspection the home has been involved in a programme leading to an Investors in People award and was due to undergo a final inspection /assessment in the weeks following this inspection. As part of their terms and conditions of employment, all staff agree to undertake N.V.Q training courses which they start following an induction/foundation course. Additional subjects such as the administration of medication, food hygiene, moving/handling and first aid are also undertaken. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 Page 18 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 17.4 of staff had been trained to N.V.Q level 2 with a further 8.7 expected to complete their course by Christmas 2005 .A further 26.1 of staff have enrolled and are involved in training. As part of her review of staff training the manager has identified a need for staff to receive more training in the care of people with dementia. Progress will be reviewed at a future visit to the home. The staff group within the home is very stable many staff having worked in the home for many 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.V266661.R01.S.doc Version 5.0 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, 32,33,35 and 38 The management of the home who safeguards the health and safety of staff and residents through the implementation of safe working practices need to introduce a quality monitoring systemn that seeks the views and opinions of residents /residents representatives. EVIDENCE: Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 Page 20 The manager who has been in post since August 2005 has been registered since the last inspection has many years of managing residential homes for the elderly is qualified to N.V.Q. level 4. In talking with staff the inspector confirmed that the manager has established clear 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. A formal quality monitoring system that seeks the views of service users has yet to be introduced however from talking to residents it was clear their views are sought on an un official ad hoc basis. 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. The inspector highlighted some uncovered hot pipes during the tour of the building; these were covered before the inspection was finished. Monthly visits that are required to be undertaken by a representative of the organisation in accordance with regulation 26 and the forwarding of the subsequent reports to C.S.C.I. 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 as were records of weekly health/ safety checks, the servicing of equipment, staff training in the techniques of moving and handling, first aid, health and safety, the procedures to follow in the event of fire (including evacuation) and accidents. Records seen confirmed all staff have received regular supervision. Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 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 3 3 2 X 3 X 3 3 Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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 Standard OP9 Regulation 13(2) Requirement The registered person is required to undertake a written risk assessment to establish who is responsible for the administration of residents drugs and medicines. The registered person is required to introduce a quality monitoring system that seeks the views of service users. Timescale for action 08/12/05 2 OP33 24(1)(2)( 3) 21/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Woodley Grange DS0000011795.V266661.R01.S.doc Version 5.0 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. 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