Inspection on 12/09/05 for Woodley Hall

This inspection was carried out on 12th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodley Hall 12/06/07

Woodley Hall 30/08/06

Woodley Hall 30/01/06

Woodley Hall 01/02/05

Woodley Hall 02/09/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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

CARE HOMES FOR OLDER PEOPLE Woodley Hall 1 Gill Court Brunswick Village Wideopen Newcastle Upon Tyne Tyne & Wear NE13 7DU Lead Inspector Aileen Beatty Unannounced Inspection 12th September 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 Hall DS0000000492.V257514.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 Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodley Hall Address 1 Gill Court Brunswick Village Wideopen Newcastle Upon Tyne Tyne & Wear NE13 7DU 0191 217 1749 0191 236 7495 manager.woodleyhall@careuk.com 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) Care UK Mental Health Partnership Limited (Arc Healthcare Limited) Miss Lisa Reid Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Forms 38/39 (Consent to Treatment) will be in place. Detained patients will be regularly informed of their rights of Appeal (Sec.132). Registered Mental Nurse staffing coverage. All detained patients will have a Responsible Medical Officer. All detained patients will have a current Section 17 (Leave of Absence). 1st February 2005 Date of last inspection Brief Description of the Service: Woodley Hall is a 20-bed Care Home, which provides nursing care for people with enduring mental illness. The residents are former patients of St Nicholas Hospital, no longer felt to be in need of acute care and able to be cared for in a community setting. Located in Brunswick Village to the north of Newcastle upon Tyne, the home is ideally located for shops, pubs, a wildfowl park and other significant local amenities which include churches and a major national racecourse. The home is staffed by Registered Mental Nurses at all times. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took 5 hours. The inspection consisted of a tour of the premises, discussions with staff and residents and a review of care records. There were no relatives or visitors present during the inspection. 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 6 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 Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 7 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): 2 and 3. Service users are given a written statement of terms and conditions upon admission to the home. All service users have their needs assessed prior to admission to the home. Intermediate care is not provided. EVIDENCE: A copy of the Statement of Purpose of the home and Service User guide is available in the reception area in the home, in addition to personal copies being supplied. These documents were reviewed and found to contain all of the required information. The name of the home manager is out of date and needs to be amended. All service users have their needs assessed before moving into the home. There are copies of these assessments in individual records. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 8 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, 9 and 10. The care needs of service users are not always set out in an individual plan of care. Medication procedures are satisfactory. Most service users feel they are treated with respect and their privacy and dignity maintained. EVIDENCE: Care records were examined, and found to contain a variety of assessment tools and care plans. The general format of care records is good. A number of care plan evaluations and assessments of physical and mental health needs were found to be out of date. This was of particular concern where deterioration in symptoms have been reported and recorded and a need for more regular evaluations identified, these have not been carried out. The general standard of the content of care plans is good. Through discussions with staff, it became apparent that staff do not always follow care plans consistently, which is confusing for support staff and potentially detrimental to residents. This is unacceptable. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 9 Medication records were examined and found to be satisfactory. A random check of controlled drugs found the correct quantity in stock. The clinical room must be kept clean and tidy and free from unnecessary clutter. Residents spoken to said that they felt that their privacy is respected. Staff were observed knocking on doors. Staff were also noticed to respond very positively to residents and were very friendly and approachable. One staff member demonstrated empathy towards a resident by not coming along after them and cleaning up which would have possibly offended the person who had already attempted to do so. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 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): 14 and 15. Service users are helped to exercise control over their daily lives. A wholesome and balanced diet is provided but not in pleasing surroundings. EVIDENCE: During the inspection staff were observed consulting with residents and routinely offering choices. There is a notice board in reception, which provides a lot of useful information to residents including local interest and advocacy services. It was noticed that so much information is provided that perhaps another notice board would be useful. Care plans are signed by residents. Where specific measures are taken which may appear to be imposing restrictions upon the freedom of some people, this is clearly recorded and closely monitored. A varied menu is provided. Most people spoken to said that they enjoyed the meals at the home. The kitchen was inspected and found to be clean and tidy. A recent environmental health inspection revealed a number of concerns and a report is available separately. These concerns are being dealt with by the home, and this includes monitoring of cleaning schedules and temperature checks by management, which has not been happening. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 11 Fresh fruit is available and fresh vegetables are also used. The cook demonstrates a good understanding of how to fortify foods for people who may be ill or underweight. He was also aware of people who require special diets, however this information was carried in his head and must be recorded in the kitchen in case replacement staff are ever working to cover for regular staff. Alternative choices are offered and special requests accommodated where possible. It was noticed that eggs were stored in a warm passageway and should be refrigerated / kept cool. Dining areas are not very pleasant as the chairs, in particular the lighter ones, are badly marked faded and stained. This was pointed out at the last inspection visit. Nice tablecloths are provided. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 12 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): 18. Staff training and experience does not meet the standard required to ensure that service users are adequately protected from abuse. EVIDENCE: A review of staff training found that there has been insufficient training in adult protection. Combined with a lack of regular staff supervision, this could potentially lead to residents not being satisfactorily protected from abuse. Staff must have training to enable them to recognise potentially abusive situations and to know how to respond accordingly. Some incidents that have occurred in the home were discussed during the inspection and it was felt that the homes own guidelines about Protection of Vulnerable adults have not always been followed. A review of this policy and training for all grades of staff is necessary. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The home is fairly well maintained but not always safe. It is not satisfactorily clean and hygienic. Some areas are pleasant. EVIDENCE: A tour of the home was conducted. The first impression outside the home is that there are a lot of weeds outside the front door. Upon entering the building there is some malodour. The majority of the home is well decorated. It was noticed that some bathrooms and toilets in particular have nice pictures and mirrors which make them homely and inviting. A variety of items are stored in bathrooms such as zimmers, hoists, slings and a commode. The sluice also contains a number of items on the floor so some shelving should be provided. An old door continues to be stored in the sluice and should be removed. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 14 The rear garden is very pleasant, with attractive planting and bird table and garden ornaments. It did have quite a few weeds and while it would not be classed as overgrown, any more would spoil this pleasant space. The two sheds at the bottom of the garden were found to be unlocked. One contained firelighters and the other contained tools, paint and white spirits. The white spirit was stored in a glass jar and not the original container. Communal areas require some refurbishment. A number of chairs and sofas are very badly marked or burned with cigarettes. Some new side tables have been provided since the last inspection but it is recommended that hospital tables are removed and similarly practical but non- institutional ones provided instead. The television in one lounge is balanced on top of video and DVD player. A unit should be provided or bracket to secure this equipment to the wall. The linoleum in some en suite bathrooms is bubbled and needs to be replaced. The majority of bedrooms are nicely decorated to suit the tastes of the people living in the home. They are comfortable and warm. The standard of cleanliness has improved slightly since the last inspection. External support was provided to carry out a one off “deep clean” of the premises and this has made some improvement. There are signs, however, that cleaning schedules are not rigorous enough to prevent the situation reoccurring. Some areas such as ledges are very dusty and obviously not routinely cleaned. A dirty mop head was found in the laundry sink in the same location as at the last inspection. Only one of the domestic staff has been signing cleaning schedules, and despite concerns about the standard of cleanliness no further training or regular supervision is in place. The radiator cover in the upstairs dining area must be removed, cleaned and the radiator cleaned. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 15 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): 30. Staff are not all fully trained and competent to do their jobs. The remaining standards will be assessed at the next inspection visit. EVIDENCE: There was no training schedule available at the inspection. Staff files examined contained only details of basic induction, moving and handling and fire safety training. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 16 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): 32,36,37 and 38. Service users do not fully benefit from the leadership and management approach of the home. Staff are not appropriately supervised. Service users best interests are not fully safeguarded by effective record keeping. The health safety and welfare of service users and staff is not always promoted and protected. EVIDENCE: The manager was not present during this inspection visit. It does not appear, however, that the home is being effectively managed at present. The evidence for this, which applies to standards 36, 37 and 38, is as follows. • There is no evidence of ongoing monitoring of performance of identified staff. DS0000000492.V257514.R01.S.doc Version 5.0 Page 17 Woodley Hall • • • • • • • There is no evidence of management audits of kitchen, cleaning or care records. Staff do not receive regular supervision (outstanding requirement) Care plans are not maintained to a satisfactory standard (outstanding requirement) The home is not satisfactorily clean (outstanding requirement) Mop heads must be cleaned after use and stored appropriately (continues – outstanding requirement). Health, safety and hygiene practices in the home are not effectively monitored. Adequate training is not provided. A record of accidents is maintained by the home. Staff also demonstrate an awareness of food hygiene by correctly labelling opened items of food in remote dining rooms. Fridge temperatures in dining rooms are not recorded regularly. Maintenance records were examined. There is evidence of regular fire training and safety checks. It is recommended that comments as to the efficiency of fire drills be recorded e.g. did staff respond appropriately in a timely fashion. The date must be included on all records of checks and not just the month. Water temperatures are carried out monthly and a Legionella test was carried out in July 2005. Records of services to specific equipment such as hoist and sluicing disinfector appeared to be out of date. Due to a change in contractor for the collection of clinical waste and sharps, there have been some difficulties. It was reported that the situation was close to being resolved, however due to a number of concerns relating to the hygiene and infection control, an infection control audit has been arranged by a specialist nurse. This will be helpful to the home in identifying weaknesses in this area. Practical advice and guidance will also be provided. Concerns in this area included inappropriate use of dish- washing sinks for hand washing and hand washing signs being pinned up over these sinks, encouraging this. The underside of a bath hoist seat was found to be very dirty. A metal waste paper bin was found in one toilet and it contained a used urine test strip. The extractor fan in the upstairs dining room was broken during the inspection and the remaining systems were inadequate to cope with the degree of smokiness. This must be repaired or replaced as a matter of urgency. Some chemicals were found to be stored incorrectly (cross ref std 19), and cleaning materials were found in the upstairs kitchen cupboard. COSHH regulations 1988 must be applied and staff training provided. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 18 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 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 1 X X X 1 2 1 Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 6(a) Requirement The information in the service user guide must be up to date. Care plans must be adhered to by all staff. Care plan evaluations must be up to date. OUTSTANDING 3 4 OP38OP26 OP32 13(3) 23(2)(d) 12,13,15, 17,18. The home must be kept clean and hygienic. OUTSTANDING The overall management of the home must improve, particularly in relation to managing • • • Care plans and records Staff training and supervision The cleanliness and infection control procedures in the home 12/11/05 12/09/05 12/12/05 Timescale for action 12/11/05 2 OP7 15(2) (b) 12/09/05 5 OP38 13(3) 13(4)a 23(2)p,c The home must comply with COSHH regulations 1988 (immediate) COSHH training must be provided. The extractor fan in the upstairs Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 20 dining area must be repaired or replaced. Comply with the recommendations of the infection control audit. Confirm regular service checks are in place for hoist and sluicing disinfector. Temperatures must be monitored in dining room fridges. Comply with the requirements of the environmental health officer. Bath hoist seat must be routinely cleaned. A system of management audit of health safety and hygiene records must be developed and implemented. 6 OP30OP36 18(2) 18(1)(c) i Staff must receive formal supervision at least six times a year. A training schedule must be developed and implemented. 50 of staff to have NVQ level 2 or above. 7 OP19 23(2)(d) Radiator covers must be removed for cleaning and replaced. Adequate storage must be available to prevent inappropriate storage. Shelves must be provided in sluice. Faded and burned chairs in lounge, dining room and the settee in the double bedroom, must be replaced. OUTSTANDING Hospital tables used in lounges must be replaced with those Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 21 12/11/05 12/12/05 more domestic in style. OUTSTANDING Bubbled lino in bathrooms must be replaced. The television must be placed on a cabinet or secured by a bracket. 8 9 OP18 OP15 18(1)(c) (i) 13(6) 16(2)(j) (i) Adult protection training must be provided. Eggs must be stored in a cool location in accordance with EHO advice. A record of all special diets must be held in the kitchen. 12/01/06 12/09/05 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 OP19 Good Practice Recommendations Regular weeding should take place. Woodley Hall DS0000000492.V257514.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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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