Inspection on 14/08/07 for Woodley House Care Home

This inspection was carried out on 14th August 2007.

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 found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodley House Care Home 30/10/06

Woodley House Care Home 16/01/06

Woodley House Care Home 25/05/05

Woodley House Care Home 03/03/05

Woodley House Care Home 24/08/04

Woodley House Care Home 02/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Woodley House Care Home Woodley Street Ruddington Nottingham NG11 6EP Lead Inspector Rehana Rashid Unannounced Inspection 14th August 2007 10:00 Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 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 House Care Home DS0000008768.V340804.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 Adults 18-65. 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 House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodley House Care Home Address Woodley Street Ruddington Nottingham NG11 6EP 0115 984 8069 0115 945 6020 rachael.steven@btconnect.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) Mr Brian McKean Miss Rachael Louise Stevenson Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th October 2006 Brief Description of the Service: Woodley House is an adapted period property that sits in its own grounds close to the centre of the village of Ruddington, which has a range of shops, churches and public houses. The accommodation is registered to accept up to thirteen service users with a learning disability and offers personal care and support. The accommodation comprises both single and double rooms and spans over three floors without a vertical lift so any potential service users would have to be fully mobile. There are a number of communal facilities and these are used flexibly. There are secluded gardens and car parking to the front and side of the building. Information about Woodley House is available in the statement of purpose and service user guide. The fees for living at the home at the time of the inspection range from £380 to £1100. These are fees agreed with different local authorities and are dependent on the needs of individual residents. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which was conducted on 14 August 2007. The inspection took place over approximately five hours. The main method of inspection was case tracking, which involved selecting two residents and examining their care records. Case tracking is used to establish if the needs of the residents are being appropriately assessed by the home and their needs are being catered for. Indirect and direct observation of practice and interaction between staff and residents was also carried out as part of the inspection methodology. A partial tour of the building was carried out. Documentation including health and safety records were also examined. Due to the limited communication of the residents, interaction between staff and the residents was briefly observed. Two staff files were examined. Two members of staff were spoken with. Prior to the inspection the Annual Quality Assurance Assessment (AQAA) was sent out to Woodley Care Home, which asked questions around the service including staffing levels and number of service users. The AQAA, which was returned to the Commission for Social by the registered manager/provider, was used within this inspection report. On the day of the inspection there was thirteen residents in residence. The assistant manager supplied much of the information provided for the inspection. A pharmacist inspector completed a site visit on 20 August 2007 as part of this inspection, which involved examining medication and healthcare records in detail. What the service does well: Daily logs and records contain good quality information relating to healthcare issues. Professionals such as Community Nurses and Speech and Language Therapists are involved with residents to ensure that their healthcare needs are met. Staff spoken with demonstrated a good understanding of the needs of the residents. Residents are provided with social activities within the home and in the community such as attending day care and going to the shops in the local village. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions procedure ensures that Woodley House is able to meet the needs of prospective residents needs. EVIDENCE: The current residents at the home have been there for a significant period of time, so there was no assessment information prior to their admissions available. Woodley House does have an admissions policy and procedure in place. The two residents case tracked care files evidenced that residents care plans are reviewed. Evidence indicated that appropriate health and social care professionals are involved in the care of the residents ensuring that the home continue to meet the residents needs. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents individual needs are reflected in individual care plans. Residents are enabled to make decisions about their lives and assistance is given where needed to manage risks. EVIDENCE: Two residents care files were examined, all had a support plan in place. Since a requirement set at the last inspection care plans are now being reviewed at regular intervals. The care plans cover health, personal and social care needs of the residents. Daily logs contain good quality information but the care plans are less consistent. For instance one resident’s daily log contains a Speech and Language Therapist assessment relating to swallowing difficulties and a food diary but there is no care plan reflecting this. One of the care files viewed showed that an individual risk has been identified but there was no risk assessment in place. The care plan was very detailed regarding the assessed need. Information on how to manage specific risks would be beneficial to help minimise risk to the resident and other people around them. Despite there being no risk assessment in place, a member of Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 10 staff spoken with had a good understanding of the risk and action to take to minimise any identified risk. Residents care plans contained information about their individual communication difficulties, and ways in which they express their feelings. . Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have appropriate personal, family and sexual relationships. Resident’s rights are respected and are offered a healthy diet. EVIDENCE: During the inspection most of the residents were out attending day care services. Staff were observed interacting with two residents who were at the home in a respectful manner. The residents were watching a DVD. Care plans viewed contained details of resident’s individual preferences. Weekly timetables are included in care files, which show a variety of activities undertaken with individual residents including day care, shopping and activities within the home. Records showed that residents have contact with relatives either they visit Woodley House or the residents go to visit their relative. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 12 Staff interaction between residents was observed to be positive, staff spoke to them in a friendly manner. Staff treat residents with respect, for instance staff practices involved knocking on doors before entering communal toilets and residents bedrooms. Food storage was clean and organised. Fridge and freezer temperatures are taken daily. Food probing temperatures are not taken daily. Menu records evidenced that residents are offered a varied and a healthy diet. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer. Resident’s physical and emotional needs are met. Medication management needs to be improved ensuring residents are protected fully. EVIDENCE: The two care files that were seen identified individual preferences and how to provide personal support taking into account resident’s individual needs. The case tracking of the resident’s files showed that residents receive regular healthcare. Visits to the GP and hospital appointments were recorded. At this inspection issues were again identified with medicine management. Boxed medication that was audited did not tally with the quantities of medication remaining in the boxes. A referral was made to a Pharmacist Inspector as issues around medication management have been identified in the last few inspections. Issues identified at the inspection on 14 August 2007 had been resolved by the time the Pharmacist Inspector visited, however further issues were identified by the Pharmacist Inspector. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 14 There are up to date medication policies in place. The daily logs and records contain good quality information but the care plans are less consistent. For example, one resident’s daily log contains a Speech and Language Therapist assessment relating to swallowing difficulties and a food diary but there is no care plan to support this. Another resident has a clear plan for his mood and behaviour and there is a daily log of levels of agitation but there is no plan for constipation/bowels even though he is prescribed 3 laxatives. Medication Administration Records (MAR) are thoroughly completed for the solid and liquid medicines, however creams are recorded less well. There are creams in stock that are not included on the MAR and there are missing signatures for those creams that are on the MAR. There are ‘PRN Action Plans’ for most ‘when required’ medicines although they need to be reviewed more frequently. The morning medication round was observed and although the medication was administered carefully and kindly the procedure did not promote privacy, independence or dignity. Three medicines are being administered to residents other than the person named on the label. Some improvements have been made to the auditing and tracking of medication since the start of this inspection, five days ago. Both of the staff spoken with have completed training on administration of medicines, including National Vocational Qualification (NVQ) units and ‘in house’ coaching. Senior staff make decisions about administering ‘when required’ medication. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are safeguarded by the homes complaints and adult protection procedures. EVIDENCE: There is a satisfactory complaints procedure, which is included in the service user guide and available in a suitable format for residents. Complaints records looked at are well maintained and showed that there have been no complaints made since the last inspection. The Commission For Social Care Inspection has received no complaints since the last inspection. The homes policies and procedures for responding to suspicion or evidence of abuse, or neglect, are satisfactory. Since the last inspection there have been no adult protection investigation. Staff spoken with demonstrated an understanding of their responsibility to alert the manager of any disclosure or suspicion of abuse. Records for two resident’s finances were viewed, one was found to be accurate. There was a small discrepancy with one residents balance. Resident’s monies are held individually and records are kept of transactions made. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodley House provides the residents with a generally clean environment. Improvements are required to the maintenance of the building. EVIDENCE: Since the last inspection there have been further changes to the environment. New flooring has been fitted throughout the ground floor. The sofa in the quiet lounge was stained. The wallpaper has been removed in some places in the middle floor bathroom. There is no toilet seat and the curtain was not hanging up. The assistant manager stated that a resident keeps pulling the curtain down. A ground floor bedroom wall had a damp patch on the wall. The Annual Quality Assurance Assessment (AQAA) states that the middle floor bathroom requires refurbishment, which is being planned by the managing director. The home is not suitable for people with mobility problems as there is no lift to the first floor. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 17 The laundry facilities are appropriate for the needs of the current residents. During a partial tour of the premises the communal areas of the premises viewed were clean and tidy. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodley House recruitment practices must be more robust to protect residents. Resident’s needs are met by trained and competent staff. EVIDENCE: Members of staff spoken with reported that staffing levels are adequate to meet the needs of the current thirteen residents. The two staff members also reported that the management are supportive. Two staff files seen at this inspection contained the necessary pre employment checks including two references. The recruitment procedure must be more robust; this will ensure residents are safeguarded from harm. Criminal Records Bureau (CRB) disclosure had been received after the staff members had commenced employment. The registered person must ensure that new staff do not commence work until all the necessary recruitment checks have been carried out which include Protection Of Vulnerable Adults (POVA) first check and a satisfactory CRB disclosure. This will ensure that residents are protected from poor practice and abuse. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 19 Two staff files viewed contained evidence of training in a number of health and safety subjects, medication administration, and National Vocational Qualification level 2 (NVQ) and Learning Disability Award Framework (LDAF), which is accredited training. Staff members spoken with demonstrated a sound understanding of their roles and responsibilities and insight into the needs of the residents. There was evidence that staff receive supervision on a regular basis and staff members did confirm this during discussions. Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well managed home, that benefits from formal quality assurance and quality monitoring systems. The health safety and wellbeing of the residents is not fully protected. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) stated that registered manager at Woodley House has NVQ 4 and the registered managers award. She has been working at the home for a number of years. The assistant manager reported that the quality audit system “quality tree” is has been introduced into the service. The most recent quality audit was carried out March 2007. Feedback seen from a sample of completed surveys was positive. A Comment from resident’s relatives included “staff are prompt to note changes in health our behaviour and keep the family informed.” At the inspection a small selection of health and safety documents were viewed. There was no record to confirm when the last portable appliances Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 21 testing took place and the gas-servicing certificate showed that this was last serviced February 2005. Food probing temperatures are not taken daily. It is good practice to record and take this daily ensuring food is served to residents at the correct temperature. Woodley House Care Home DS0000008768.V340804.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 Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 2 X Woodley House Care Home DS0000008768.V340804.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. 1. Standard YA6 Regulation 15 Requirement The registered manager must ensure care plans are updated to reflect changing needs. This will ensure that the residents identified needs are met. The registered manager must ensure a risk assessment is in place for all identified risks. This will ensure that action is in place to minimise any identified risk. The registered person must ensure medication must be administered in a way that promotes privacy, independence and dignity. Medicines must only be administered to the person for whom they were prescribed. There must be no sharing of medicines. The registered person shall ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. Where work has been identified this should be repaired or replaced. The registered person must ensure that new staff do not DS0000008768.V340804.R01.S.doc Timescale for action 28/09/07 2. YA9 13 28/09/07 3. YA18 12 (4)a 09/10/07 4. YA20 13(2) 11/09/07 5. YA24 23 02/11/07 6. YA34 19 14/09/07 Woodley House Care Home Version 5.2 Page 24 7. YA42 23.4 commence work in the home until all the necessary recruitment checks have been carried out which include POVA first check and a satisfactory CRB disclosure. These checks need to have been applied for and obtained before staff commence employment. This will ensure that residents are protected from poor practice and abuse. The registered person must 28/09/07 ensure the health and safety of residents and staff, by ensuring that equipment including PAT and gas servicing are serviced or tested as recommended by the appropriate regulatory body. 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 YA6 Good Practice Recommendations The registered manager should document all consultation with service users and their relatives / representative over the development and review of care plans. The registered person should ensure that food-probing temperatures are taken daily and documented. This will ensure food is served to residents at the correct temperature. 2. YA42 Woodley House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 House Care Home DS0000008768.V340804.R01.S.doc Version 5.2 Page 26 - 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. 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