Inspection on 23/08/05 for Woodrow Retirement Home Ltd

This inspection was carried out on 23rd August 2005.

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

Woodrow Retirement Home Ltd 06/06/07

Woodrow Retirement Home Ltd 17/01/07

Woodrow Retirement Home Ltd 06/12/05

Woodrow Retirement Home Ltd 08/03/05

Woodrow Retirement Home Ltd 11/05/04

Similar services:

The Vicarage

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5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOMES FOR OLDER PEOPLE Woodrow Retirement Home Asheldon Road Wellswood Torquay Devon TQ1 2QN Lead Inspector Michelle Finniear Announced 23 August 2005 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. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodrow Retirement Home LtdAshel Address Asheldon Road Wellswood Torquay TQ1 2QN 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) Woodrow Retirement Home Ltd 01803 213026 Mr Peter James Edwards CRH 16 Category(ies) of Physical Disability over 65 Years (16) registration, with number of places Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: That Peter James Edwards completes his Managers award. Imposed 05/03/04. Date of last inspection 8/3/05 Brief Description of the Service: Woodrow care home offers accommodation with personal care to older people (60/65 ) and older people with physical disability. It is registered to provide a service for up to 16 residents both male and female. Accommodation is laid out over 2 levels with a stair lift connecting the ground and first floors. The home offers 14 single bedrooms, 12 of which have en suite facilities and 1 double en suite bedroom (which is currently being used as a single). There is also 1 communal assisted bathroom. In terms of communal space, the home has a dining room with small lounge area, a separate lounge/sun room and an attractive and accessible garden. The building itself is a large detached property located within walking distance of Wellswood village and a short bus ride from Torquay town centre with its range of shops and amenities. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced, which means the home was given advance notice of the inspection, and took place over one visit, totalling 6 hours in August 2005. To complete the inspection a tour was made of the home; eight service users were interviewed; two members of staff and one visitor was spoken to; time was spent with the homes management and various records were inspected, such as care plans, the fire log book, medication records and staff files/ training records. Prior to the inspection two service users and three relatives completed comment cards about the home. What the service does well: What has improved since the last inspection? Since the last inspection the homes electrical systems and portable appliance testing has been carried out to improve safety for service users. Improvements have been undertaken to the medication systems, in particularly to the care and recording of controlled medication, which has improved safety for service users. Fire doors are no longer held open by the use of wooden wedges, cushions or other objects, reducing risks in case of fire. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 6 Staff training has been provided in infection control, and the home has obtained a homely remedies policy signed by the local general practitioners, reducing risks of cross infection or side effects from non prescribed medication. 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. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.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 Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.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, 6 Woodrow has a pre-admission process that allows for needs assessments to be undertaken, and ensures that service users have a say in the admission process, but this could be better documented. The home does not cater for intermediate care. EVIDENCE: The home does not cater for intermediate care. This means the home does not as an example plan to provide intensive programmes of rehabilitation. Discussion was held on the most recent admission to the home, and the process that had been involved in determining the appropriateness of the placement. This had included gathering information from a carer in relation to the service users needs. The service user then assisted in completing a preadmission questionnaire, and visited the home to look at the room that had been chosen for them, but this process was not documented. There was no Social Services assessment available in this instance, as the service user was privately funded. Evidence was available to demonstrate that the home had written to the service user to confirm they were able to meet their needs in respect of Health and welfare. Appropriate pre-admission assessments are Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 9 very important as they mean the home is sure that they can meet the service user needs before the service user makes a commitment to come into the home. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 Care plans were provided for each service user but these do not contain full information on each service users needs. Medication systems were generally satisfactory, but some attention was required to the storage of controlled medication. EVIDENCE: Each service user at Woodrow has a plan of care linked to a needs assessment. This means that service users needs have been identified so that staff can ensure they are working consistently to give the person the care they need in a way that reflects their wishes. Four plans were sampled however and found in many cases to be incomplete, particularly with reference to social and medical history. Completion of these plans will benefit service users with memory and communication problems, as staff will have more knowledge about their personal history and preferred lifestyle choices. Day to day care needs were generally addressed appropriately in the service user plans, however one plan made no mention of a small sacral sore being dressed by a district nurse, and another had no mention of a dressing being carried out by care staff. It is important all areas of need are identified in the service user plan to ensure consistency of care and enable effective reviews. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 11 Evidence was seen in files of access to healthcare services such as district nurses, general practitioners and community specialists such as continence advisors. One service user confirmed in discussion that they had been taken to see their GP that morning. The home uses a monitored dosage system for the administration of medication. This means that the pharmacist pre-fills an individual cassette with medication for each individual. This system minimises risks in giving the wrong medication and allows for staff to see immediately whether medication has been given. Discussion was held on the storage of controlled medication, which was not satisfactory in one instance. The home has a controlled drug register, and a policy for the use of homely remedies. This details which ‘over the counter’ medications are approved for general issue to service users without risk of side effects of interactions with other medication prescribed. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Dietary needs of service users are well catered for with a balanced and varied selection of food available. EVIDENCE: Activities and service user lifestyle choices were not explored during this inspection however two pre-inspection comment cards indicated a wish for more organised activities at the home – “I would like to see a few outings provided i.e. out on a day trip for afternoon tea or a trip to the moors” and “Activities were stopped as there was no-one to participate only being 15 in the home”. This will be explored further at the next inspection. The home has a menu planner offering home cooked food that is varied and nutritious. On the day of the inspection service users were being served fruit juice as a starter, ham and parsley sauce, carrots, swede, cauliflower cheese and roast and creamed potatoes for lunch. Dessert was home made rice pudding or lemon meringue pie, followed if wished by cheese and biscuits and tea or coffee. Service users spoken to confirmed that the food was good, one commenting “We’re very well fed. It’s always very appetising”. The home owner confirmed the home was able to cater for some specialist diets, although none are being provided at present except for respecting of service user choices. Meal supplementation is provided if needed. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 13 Staff were seen to be respecting service user privacy by knocking on doors before entering wherever possible and service users bedroom doors have locks fitted so that service users can lock their rooms when out of the home. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 The home has a complaints procedure which ensures service user views are listened to and acted upon. EVIDENCE: The home has a clear, accessible complaints procedure included in the service user guide, which has been issued to all service users. The procedure is also on display within the home. The procedure contains appropriate timescales for investigating and responding to complaints and the name and address of the Commission for Social Care inspection. No complaints have been received concerning the service since the last inspection, and service users confirmed that they were clear who they would need to go to if they had a complaint or concern. The home has a copy of the local adult protection policy and procedure, The Alerters Guide, which is compiled in accordance with the Department of Health guidance No secrets. Staff have received some training on adult protection and there are policies for prevention of abuse and Whistle blowing available. Staff have signed a record to say they have seen the policy. Service users at the home are registered voters, either through postal votes or if they wish they could be taken to the local polling station. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 Woodrow provides a comfortable living environment, offering service users an attractive and homely place to live. EVIDENCE: Woodrow is a period property, situated in a residential area of Wellswood, within a reasonable distance of local facilities and services and set within attractive gardens. There are parking facilities at the home and nearby free on street parking. Rooms vary in size and shape from those well in excess of the minimum standard, providing lounge, bedroom and ensuite areas, to other rooms which fall just below the current minimum size. Many rooms have period features, such as fireplaces and large bay windows. The home is on two main floors with a mezzanine floor to the rear and a purpose built extension on the ground floor. All areas of the home seen on this visit with the exception of one room were odour free. This means service users have an attractive environment in which to live. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 16 The home has a communal dining room and a small sun lounge/conservatory. Plans are in hand to improve this facility to provide improved lounge facilities, which will enhance the environment for service users. The environmental health officer last visited the home on 20/7/05, and made only minor recommendations. Evidence could be seen of regular fire tests, drills and instructions, tests of extinguishers and alarms in accordance with the Fire precautions (workplace) risk assessment. This means service users are protected in case of fire. Water temperature regulators have been fitted to all outlets to which service users would have access according to the owner to protect service users from scalding and radiator covers have been provided to protect service users from coming into contact with hot surfaces. Evidence of Employers liability insurance was seen with a renewal date of May 2006. The home does not cater for service users with severe disability. An environmental assessment has been undertaken which indicates the premises are suitable for the current level of disability. Aids and adaptations include a specialist bath with hoist, raised toilet seats, grab rails and a chair lift to access the mezzanine floor level. This means service users physical care needs can be met at the home. The laundry was not seen on this inspection, however is sited in a shed to the rear of the building. The previous report indicated that hand-washing facilities were not available in this area and the laundry floor finish is not impermeable, but is readily cleanable. The home has policies for control of infection, and training has been given to staff in this area. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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, 29 The home has a well- established staff group, who know the service users and their needs well. The homes recruitment processes however do not fully protect service users. EVIDENCE: An examination was made of the homes staffing Rota. The staffing Rota and evidence from service users indicated that sufficient staff were on duty to provide care to meet service users needs. This was backed up by three relatives/visitors comment cards which indicated that in the opinion of the respondents there were always sufficient numbers of staff on duty. Staff records were examined for three members of staff, including one newly appointed to work at the home. Files did not indicate that all records required had been obtained either for the more established staff, or for the most recently appointed. Records missing for the most recently appointed staff member included a medical statement, two references, an application form and evidence of the induction process followed. One other member of staff had a complete file. A full and thorough recruitment process is important to ensure service users are protected and cared for by people who are suitable to be looking after potentially vulnerable people. Training records are important to evidence the training that a member of staff has undergone, within their current employment or previously, to ensure that the member of staff has sufficient skill to undertake the care tasks required at Woodrow. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 18 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) 36, 38 Staff supervision systems have not been fully implemented at the home. Health and safety and welfare arrangements seen on this inspection were satisfactory, ensuring service users live in a safe environment. EVIDENCE: Staff supervision systems have not been fully implemented at the home. Supervision is a system for performance evaluation, personal development and for supporting staff in their day-to-day tasks. It should ensure consistency in approach and practice for staff, thereby benefiting service users as well as ensuring that staff meet their full potential. The last recorded supervision undertaken was in 2003. Arrangements for meeting the health safety and welfare arrangements were examined start staff have received some training in health and safety practices, and risk assessments were available for environmental hazards, staff work practice issues and service user based activity. Risk assessments are a Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 19 formal way of assessing, evaluating and reducing or removing risks within the working and living environment. This means service users are protected from foreseeable risk as far as possible through practices such as training, alterations to the environment, or working practices such as ensuring cleaning materials are kept securely. Window opening risk assessments were not inspected on this occasion. The homeowner stated he has had an environmental assessment undertaken for the risks of legionella, and evidence could be seen of the regular servicing and maintenance of equipment within the home such as the bath and hoist. The home has a policy of the not lifting service users manually if they require assistance, and therefore has a hoist available for use in service user rooms if required. Staff have received some training in first aid and food hygiene practices, as well as infection-control. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x x 1 x 3 Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 21 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 OP29 Regulation 19 Requirement The home must obtain all required records prior to appointing a new staff member. Records must be obtained for those staff already employed. Care staff must be appropriately supervised Timescale for action By 30/10/05 2. OP36 18(2) By 30/10/05 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 OP7 Good Practice Recommendations Service user plans should provide sufficient detail as to the action that needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of the service user are met. The home should expand upon the current quality assurance questionnaires to provide a full quality assurance and quality control system for the home. Results of the report should be made available. Care staff should receive formal supervision at least 6 times a year (Standard 36.2). Supervision should cover all aspects of practice, the philosophy of care in the home and the staffs training and career development needs (Standard 36.2). Risk assessments should be carried out in relation to D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 22 2. OP33 3. OP36 4. OP38 Woodrow Retirement Home Ltd 5. 6. 7. OP30 OP38 OP12,13 window restrictors and such devices fitted as necessary (Standard 38.3). The home should provide training for staff in Dementia and memory loss as part of a complete training and development programme. Risk assessments should be carried out in relation to window restrictors and such devices fitted as necessary (Standard 38.3). The home should examine the current level of service user activities provided at the home to ensure it meets the needs and wishes of all service users. Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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 Woodrow Retirement Home Ltd D54-D07 S59136 Woodrow retirement home V232156 230805 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!