Inspection on 30/01/06 for Woodley Hall

This inspection was carried out on 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Hall 12/06/07

Woodley Hall 30/08/06

Woodley Hall 12/09/05

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 30th January 2006 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.V275916.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 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.V275916.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 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). Forms 38/39 (Consent to Treatment) will be in place. Detained patients will be regularly informed of their rights of Appeal (Sec.132). 12th September 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.V275916.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 30/01/06 and 31/ 01/06 and included a review of records, discussions with staff and residents and a tour of the premises. It found that the overall standard of care is good. What the service does well: What has improved since the last inspection? The requirements set at the last inspection have been fully or partially met. Training is up to date. Staff supervision has improved, and cleanliness has improved. Some new furniture has been bought. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 Page 6 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.V275916.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. All service users have their needs assessed before moving into the home. There are copies of these assessments in individual records. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, and 10. Care needs are set out in an individual plan. Health care needs are fully met. Service users feel treated with respect and their right to privacy is upheld. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 Page 10 EVIDENCE: Care plans were examined and found to be up to date and contain sufficient detail. Each service user has an individual file containing pre-admission assessment dependency rating and other physical assessments, Night duty assessment, and social assessment. Specific health needs are addressed. It is recommended that where someone is deemed high risk (e.g. of developing a pressure sore), a preventative plan be put in place. The home have regular visits from the consultant Psychiatrist involved with the residents and are well supported in meeting their Psychiatric needs. Care records examined were wound to be up to date and reviewed regularly. Residents were treated with respect by staff who, addressed them in an appropriate manner and were noticed knocking on doors before entering. Some residents were able to confirm that they feel they are treated with respect. One resident did not feel treated with respect but said they did not wish to live in the home. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 Page 11 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 13. Service users are able to carry on a lifestyle that meets their social religious and recreational needs. Service users are encouraged to maintain contact with family friends and representatives. EVIDENCE: Residents were independently enjoying a number of activities such as going for a cup of tea at a centre nearby, or visiting the local shop during the inspection. One resident said he had recently been out for a bar meal which he had thoroughly enjoyed. There were no visitors present during the inspection but they may visit at any reasonable time and see their friends in private. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 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): 16 and 18. Satisfactory complaints and adult protection procedures are in place. EVIDENCE: There have been no complaints received by the home since the last inspection. Satisfactory complaints procedures are in place. The scope of issues that should be forwarded to Adult Protection Services was discussed. It was acknowledged that it might be difficult to determine what may be a true allegation when someone has a history of delusional thinking. It was agreed that serious allegations must be referred to POVA (Protection of Vulnerable Adults), with the home giving their opinion as to whether they feel illness may be a contributing factor. It is then the role of POVA to decide whether to proceed with a strategy meeting. Staff training in the protection of vulnerable adults has been carried out. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 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. Service users live in a safe well-maintained environment. It is satisfactorily clean and hygienic. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 Page 14 EVIDENCE: There has been some new furniture purchased since the last inspection. The bed tables in the lounge have been replaced. The replacement of chairs is ongoing, but some may be re upholstered which is an option currently being considered. Resident’s rooms remain nicely personalised and homely. The clutter has been removed form the sluice and the spare door removed. Shelves are now on the walls, which is a big improvement. A new extractor fan is now upstairs. A bracket is still required to secure the TV. There has been an improvement in the standard of cleanliness in the home. There is evidence that the deputy manager has been auditing a number of areas in the home and recording findings. This has led to an improvement in adherence to procedures. One resident commented that the home now “smells clean”. A hygiene audit has bee carried out and all recommendations put into place. The laundry was clean and tidy, with washed mop heads drying hygienically. All linen was in slips and there was no dirty laundry on the floor. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 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): 29 and 30. Service users are protected by recruitment procedures in the home. Staff are trained and competent to do their job. EVIDENCE: Staff files were examined including the most recently appointed. They contained details of application form, interview record, references, company confirmation of receipt of CRB (criminal records checks) at head office, and the required identification. Recruitment procedures are met. A record is maintained of qualified nurses PIN numbers. A training programme has been reintroduced in the home. Statutory training has been prioritised. There is evidence of in house teaching where the deputy Manager has been coaching some staff regarding care plans. There is written feedback in staff files. The improvement in care records demonstrates that this has been effective. Last year, a representative from the health and safety executive recommended training in violence and aggression. This has been carried out under the title “challenging behaviour”. It is recommended that a record be held in individual nurses files detailing the training they have received, which contributes to them meeting the requirements of their registration. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 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): 31,36 and 38. Service users are living in a home, which is being managed by a person able to meet their responsibilities. Most staff are appropriately supervised. Health safety and welfare of service users are promoted and protected. EVIDENCE: There is currently no permanent manager in post. It has not been possible to fully inspect this standard. A deputy manager has been in post, and has been supported by a manager from a sister home and senior management. It appears that the home has been well managed during this time. The Deputy manager has completed the Registered Manager’s Award. Staff supervision has improved, at around 75 up to date. It was agreed that the format for supervision should be reviewed, as there appears to be two Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 Page 17 systems in place running alongside one another. It was also suggested that some general issues could be addressed via group supervision to work through the backlog until a better system is in place. There are good systems in place for the maintenance of a safe environment. During a recent independent audit, the home scored 93 . Most staff have received training in COSHH (hazardous substances). Additional training in infection control is being sourced but may be provided by the Trust. There were no hazards identified during this inspection. Routine inspections of hoist have been carried out. Regular Legionella testing is carried out. Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 2 X 3 Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 Page 19 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 OP19 OP8 OP19 OP30 Regulation 23 (2) (b) Requirement Timescale for action 31/05/06 31/01/06 31/03/06 31/01/06 The programme of replacing furniture must continue until chairs are satisfactory. 13 (4) (c) Preventative care plans must be in place where risk is identified during assessment. 13 (4) (a) The TV must be fixed to bracket. 18(2)18(1 Staff must receive formal )(c) i supervision at least six times a year. 50 of staff to have NVQ level 2 or above. OUTSTANDING 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 OP30 Good Practice Recommendations It is recommended that there is an up to date record of training carried out by nurses to meet the requirements of their registration. DS0000000492.V275916.R01.S.doc Version 5.1 Page 20 Woodley Hall 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. Extracts may not be used or reproduced without the express permission of CSCI Woodley Hall DS0000000492.V275916.R01.S.doc Version 5.1 Page 21 - 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!