Inspection on 19/09/05 for Woodmarket House

This inspection was carried out on 19th September 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

Woodmarket House 15/12/08

Woodmarket House 03/01/07

Woodmarket House 09/06/05

Woodmarket House 11/01/05

Woodmarket House 09/08/04

Woodmarket House 10/03/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodmarket House Woodmarket Lutterworth Leicestershire LE17 4BZ Lead Inspector Linda Clarke Unannounced 19 September 2005, 9:10am th 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 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. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodmarket House Address Woodmarket Lutterworth Leicestershire LE17 4BZ 01455 552678 01455 552678 None Leicestershire County Council Social Services Telephone number Fax number Email 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 David Merry Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Learning registration, with number disability over 65 years of age (4), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (40), Physical disability over 65 years of age (10), Sensory Impairment over 65 years of age (4) Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No person falling within category DE(E) may be admitted to the home when 20 persons who fall within category DE(E) are already accommodated. No person falling within category MD(E) may be admitted to the home when 6 persons who fall within category MD(E) are already accommodated. No person falling within category LD(E) may be admitted to the home when 4 persons who fall within category LD(E) are already accommodated. No person falling within category PD(E) may be admitted to the home when 10 persons who fall within category PD(E) are already accommodated. No person falling within category SI(E) may be admitted to the home when 4 persons who fall within category SI(E) are already accommodated. Service users between the age of 55-65 who fall within the above categories and were resident in the care home at the date of registration may continue to reside there. To be able to admit the named person under the age of 65 named in variation application No. V18575 dated 23rd March 2005. Duration of stay for the service user named in variation application No. V18575 shall not carry on past 13th April 2005. Date of last inspection 9th June 2005 Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 5 Brief Description of the Service: Woodmarket House is a care home providing personal care and accommodation for forty older persons. Woodmarket House has two respite beds, two assessment beds and four beds dedicated to rehabilitation. The forty single bedrooms are without ensuite facilities. The home has a large garden which is well maintained and which is accessible to all residents resding in the home. The premise is owned by the Leicestershire County Council Social Services Department and is situated close to Lutterworth, where residents have access to shops, pubs, the post office and other amenities. The home is easily accessible by private or public transport. Accommodation is provided over two floors with access between the floors being via a stairs or passenger lift. Communal areas are provided on both floors with a loop system in the main lounge for service users with a hearing impairment. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place between 9.10am and 2.15pm. The opportunity was taken to look around parts of the home, spend time with residents, view records and policies which, included viewing the care plans of four residents residing at the home. The Inspector interviewed two members of care staff and spoke with two relatives who were visiting. The Registered Manager and Assistant Manager facilitated 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. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 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 standard(s) 3 The admission process is well managed with residents needs being assessed ensuring staff have the appropriate information to meet individual needs. EVIDENCE: The Inspector viewed the records of four residents all of which contained a comprehensive assessment undertaken by a Social Worker prior to admission. On the day of the Inspection the rehabilitation unit did not have any occupants and therefore this standard was not assessed on this occasion. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 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 standard(s) 7, 8, 10 and 11. Residents are looked after well in respect of their health and personal care. EVIDENCE: Care plans begin by detailing a brief life history of residents, with information as to where they lived, their work, family life, hobbies and interests. This information provides a platform for staff to appreciate an individual’s life prior to residential care. Care plans of four residents’ were viewed; care plans detailed the care needs of residents, which incorporated physical health, mental health where appropriate and including specific information pertaining to illness and death, where indicated by residents and/or relatives. The level of information pertaining to mental health within care plans has improved since the last Inspection, the Registered Manager stated that the effect of mental health on an individual was being applied to all aspects of care and recorded within the daily living arrangements within the care plan. Risk assessments were also incorporated; ensuring areas of risk to residents are managed, with particular reference to falls. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 10 Records evidenced contact with health care professionals, which included General Practitioners, District Nurses and Opticians. The Inspector spoke with a District Nurse who attended various residents on the day of the Inspection, who stated that she was satisfied with the level of care residents received, and that any causes for concern were brought to her attention. The District Nurse only had one concern in that there were on occasions staff shortages. The Inspector spoke with two visitors who were visiting at the time of the Inspection both were happy with the level of care their relatives received. Both expressed concerns as to the number of care staff on duty on occasions. The Inspector spoke with residents who stated that staff at the home was caring, and that they liked living at Woodmarket House. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 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 standard(s) 12, 13 and 15. Residents experience a homely life style and visitors are encouraged to visit. Various formal and informal activities are made available to residents. EVIDENCE: The home has recruited an Activity Organiser who also works part time as a member of care staff. No schedule of activities was in place, however residents and relatives spoken to confirm that ‘sing a longs’ were very popular. Care staff interviewed said that in addition quizzes, music and movement and ball games take place. Excursions are also organised monthly, transport being provided through the Volunteer Bureau, destinations have included Twycross Zoo, Black Country Museum, pub lunches and garden centres. It is recommended that residents are consulted as to their interests, and that a timetable encompassing their preferences is developed and implemented. Daily records detailed residents participation in some recreational activities, this could be further developed to include when residents decline to take part in activities, and if they do the activity they took part in and any comments that they make. Records evidenced contact with relatives and friends. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 12 Residents were asked by the Inspector as to their views on activities offered, all confirmed that they enjoyed the sing a long sessions, one lady said that she would like to play bingo more often. Residents said that they missed the Activity Organiser as he was currently on holiday. Both visitors spoken with stated that their relatives enjoyed the sing a long sessions. A visitor spoken to expressed a concern that when she arrived to visit her relative at 10 o’clock, her relative for breakfast was served burnt bacon and tomatoes, which she was not able to eat, the activity organiser who was at that time working as a member of care staff was serving breakfast, and provided the resident with an alternative. The impact on residents in relation to their involvement in activities should be considered when the Activity Organiser/Care Assistant is involved in care duties. The views of residents to whom the Inspector spoke with, was that meals were of a good quality. The minutes of a residents meeting held in May 2005, recorded that residents views pertaining to meals and the menu were sought, it is recommended that this again be discussed at the next resident meeting. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 13 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 standard(s) EVIDENCE: Standards within this section were not inspected on this occasion. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 14 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 standard(s) 19 and 20. A comfortable and safe standard of accommodation is provided for the resident’s including a garden area, which individually and collectively meets the resident’s needs. EVIDENCE: Woodmarket House is well maintained and suited to the needs of residents. It is decorated and furnished to a standard that creates a comfortable and homely environment. The home has spacious sitting rooms on both the ground and first floor, which offers residents a variety of choices as to where to sit and relax or watch television. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30. Staff at the home are training, however resident’s needs are not met on all occasions. EVIDENCE: The Registered and Assistant Manager confirmed that they aim to have five members of care staff on duty in the morning, with four staff on in the afternoon/evening. The Inspector viewed the staff rota for the week of the Inspection; on all but one morning there were either three of four members of staff on duty, with three being on duty throughout the week in the afternoon. The Managers confirmed that additional staff cover was needed, and that they would use agency staff should staff employed by the home not be able to cover the shortfall. The Registered Manager stated that currently the assessment and rehabilitation unit were not occupied to full capacity. The Inspector also noted that previous, and future rotas reflected that four care staff was anticipated to work in the morning at weekends, one less that during weekdays. Care staff interviewed could not confirm as to levels of care staff at weekends, one member of staff did state that there are less ancillary staff on duty at weekends, and on occasions less kitchen staff during the week, the result of this is that care staff perform the duties of ancillary staff, affecting the number of staff delivering care to residents. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 16 The Registered Person and Manager need to review the staffing levels, to ensure that residents receive a consistent level of care at all times. One relative was concerned that on occasions, when staff are having a handover no care staff are available to oversee the welfare of residents. This point was put to the Registered Manager who confirmed that this happened on very rare occasions. One relative relayed a specific occasion, that when she visited her relative, she could not locate a member of staff, having looked in the lounge, dining room and officer. Her concern was that should a resident fall, a member of staff would not be aware. It is recommended that the deployment of staff within the home be reviewed to ensure the health and welfare of residents. The District Nurse expressed concerns that there was not always sufficient staff on duty. Woodmarket House currently employs twenty members of care staff of which nine have attained a level 2 National Vocation Qualification in Care, with one member of staff attaining a level 2 and 3. One Assistant Manager has attained a level 2 National Vocational Qualification, with two members of the management team being National Vocational Qualification Assessors. Staff training records along with two care staff interviewed, confirmed a training schedule, which encompassed health and safety, moving and handling, first aid and risk assessment. Courses also encompassed other aspects of training including Alzheimer’s, Parkinson’s and an Introduction to Mental Health. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 36. The systems in place ensure that resident’s finances are managed appropriately. Records evidence the involvement of residents in the day-today running of the home. EVIDENCE: Resident meetings are held on a regular basis, with minutes of meetings being taken. Meetings provide residents with an opportunity to comment on the running of the home and affect change. Staff meeting minutes were viewed, the most recent full staff meeting having taken place in November 2004, the Registered Manager confirmed that subsequent meetings have taken place involving staff consistent to the work they are employed to undertake. Staff interviewed confirmed that they receive regular supervisions from a member of the management team. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 18 The Inspector noted that care plans detail how resident’s finances are managed. In some instances the resident’s family manages this, whilst managerial staff within the home manages others. The Inspector viewed the records of those residents’ finances that are managed by the home; two persons sign all financial requests with receipts being kept. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x x x STAFFING Standard No Score 27 2 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 3 x 3 3 x x Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 20 No 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 27 Regulation 18(1) Requirement The Registered Person to review the current care staffing levels, to ensure that the needs of residents are met at all times. Timescale for action 1st December 2005 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. 2. 3. 4. 5. Refer to Standard 12 12 12 15 18 Good Practice Recommendations It is recommended that residents are consulted as to their hobbies and interests, which are then reflected within a weekly activity timetable. It is recommended that residents particiption in activites and recreational pursuits be recorded, along with any views which they express. It is recommended that the impact on residents with regards to their participation in activities be reviewed when the Activity Organiser is engaged in care duties. It is recommended that residents views be sought with regards to meals at the next resident meeting. It is recommended that the deployment of staff be reviewed, to safeguard residents welfare. Woodmarket House 20050919 Woodmarket House X00015 UN Stage 4 S32528 V242520 C51.doc Version 1.40 Page 21 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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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