Inspection on 15/11/07 for Woods Court Care Home

This inspection was carried out on 15th November 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woods Court Care Home 09/01/09

Woods Court Care Home 16/11/06

Woods Court Care Home 22/02/06

Woods Court Care Home 08/09/05

Woods Court Care Home 25/03/05

Woods Court Care Home 02/02/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Woods Court Care Home Hatton Gardens Newark Nottinghamshire NG24 4BP Lead Inspector Richard Ramsden Unannounced Inspection 15th November 2007 10:00 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 DS0000035542.V352145.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 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. DS0000035542.V352145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woods Court Care Home Address Hatton Gardens Newark Nottinghamshire NG24 4BP 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) 01636 673548 F/P 01636 673548 tala.hobson@nottscc.gov.uk Nottinghamshire County Council Miss Caroline Ann Falshaw Hobson Care Home 49 Category(ies) of Dementia (20), Dementia - over 65 years of age registration, with number (20), Old age, not falling within any other of places category (49), Physical disability (10) DS0000035542.V352145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Out of the total number of beds (49), there will be 20 beds for DE 55 and over and/or DE(E Out of the total number of beds (49), 10 may be used for PD 55 and over A maximum of 5 PD 55 years and over to be accommodated outside the intermediate care unit Service users shall be within category OP Date of last inspection 16th November 2006 Brief Description of the Service: Woods Court is a care home providing personal care and accommodation for 49 older people, 10 of which receive intermediate care. It is owned and run by Nottinghamshire County Council. The home is located within easy walking distance of Newark town centre where there are a variety of shops and facilities. The home was opened in 1988 and consists of a two-storey purpose built property, divided into five units. There is a shaft lift to assist independent access between levels. All of the bedrooms are for single occupancy, with wash hand basins. None of the rooms have ensuite facilities. The gardens are well tended and are accessible by service users. The inspector was advised that there is a secure garden area leading directly of one of the units, which has been specially designed for people who have dementia. The weekly accommodation charges for those residents who are self funding would be £377.00. A copy of the most recent inspection report was available in the home. DS0000035542.V352145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced visit over one day it took approximately 6 1/2 hours. It included the inspection of care and other records, a discussion with the manager and a member of care staff. An ‘expert by experience’ was used at this inspection. The role of the ‘expert by experience’ is to talk with residents. The ‘expert’ is arranged through the charity Help the Aged. An ‘expert by experience’ means they have experience and skills to be able to speak with residents at an inspection. Their experience could be from previous work or they may have used care services themselves. The ‘expert by experience’ spoke with thirty-one residents and a number of relatives. The inspector spoke with three residents and one visitor. Two residents satisfaction questionnaires and one relative/advocates satisfaction questionnaire was received prior to this inspection. A partial tour of the building was also completed. Two residents were case tracked, which means that their care plans were examined against the actual care they receive. Prior to completing this visit the inspector assessed the home service history, the Pre-inspection information provided by the homes manager and the last inspection report. The manager was informed that The Commission for Social Care Inspection might remove some same of the homes conditions of registration in the near future. This process was discussed in detail including the manager’s responsibility to ensure that the home can always meet the needs of all residents admitted to the home. What the service does well: The expert by experience described Woods Court as “A (caring) home from home”. The people living at Woods Court and their representatives appear genuinely satisfied with the services provided. The expert by experience spoke to a number of visitors and stated that “they were full of praise for the care and attention that their friends and kinfolk received”. DS0000035542.V352145.R01.S.doc Version 5.2 Page 6 The home is well managed and run in the best interests of the residents. The expert by experience stated, “ The manager was very busy and hands-on. She quietly and efficiently responded to each request for her time or action”. Residents and staff spoken with during the inspection confirmed that they have confidence in the managers abilities and that they are involved in the decisionmaking within the home. People said that they are very satisfied with their bedrooms and confirmed that they had been encouraged to personalise them with small items of furniture photographs etc. The care staff are well trained and over 63 have completed National Vocational Qualifications to level 2 or above. The experienced and well trained staff helped to provide continuity and stability for the residents. Care plans are comprehensive and reviewed frequently enough to ensure that staff always know what assistance and support each resident requires. Health care records are also well maintained. Residents said that the care staff are always friendly and respectful and ensure that their privacy and dignity is maintained at all times. The expert by experience stated “ I sat for two hours in the afternoon-just observing and was most impressed by the courtesy and care given to everyone”. There were many aspects of good practice highlighted in the main body of this report. What has improved since the last inspection? Some areas of the home have been refurbished since the last inspection. There have been significant improvements in the information contained in the resident’s individual care plans and people are now being encouraged, where possible, to sign their care plans to confirm their involvement in the planning and review process. New comprehensive risk assessments have been introduced for those residents who wish to administer their own medication. This helps to ensure the health and safety of all residents in the home. The home is now displaying a program detailing all activities, entertainment and outings to be provided for the residents on a monthly basis. The expert by DS0000035542.V352145.R01.S.doc Version 5.2 Page 7 experience stated “A giant ‘Activities for the month’ programme was in full view. Visitors and to those in care were busy checking what would be on.” The manager is now keeping a central record of all complaints to provide an overview of the nature and frequency of complaints received. 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. DS0000035542.V352145.R01.S.doc Version 5.2 Page 8 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 DS0000035542.V352145.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6. Staff are ensuring that they can meet the assessed needs of prospective residents by obtaining preadmission assessments. Intermediate care services are helping to maximise resident independence and where possible enable them to return home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents records were assessed as part of this inspection. Both of the records contained preadmission assessments, which had been completed by a social worker. DS0000035542.V352145.R01.S.doc Version 5.2 Page 10 Terms and conditions of residence documents, which had been signed by the residents, where possible, were available on each of the files viewed during this visit. One of the residents in the intermediate care unit was spoken with during this visit. She was full of praise for the services provided by the home and said that the physiotherapy she had received had enabled her to walk again, thus increasing her chances of returning home. She confirmed that she had completed a home assessment on the day prior to this inspection and was hoping to return home in the near future. DS0000035542.V352145.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Residents individual care plans contain sufficient information and are reviewed regularly enough to ensure that staff are always aware of what support and assistance each resident requires. The homes medication is well managed and residents believe they are treated with respect. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents care plans were viewed as part of this visit. The care plans have improved significantly since the last inspection and now contain sufficient information and were reviewed frequently enough to ensure that staff up-todate information about the care and support each resident requires. DS0000035542.V352145.R01.S.doc Version 5.2 Page 12 Where possible individual residents have signed their care plans to confirm their involvement in the care planning and review process. (This is good practice). All of the care plans are viewed, during this visit, contained photographs of the individual residents, this helps staff to identify which residents are care plans referred to. Records show the residents health care needs are being appropriately met; the three residents and one visitor who were spoken with during the inspection confirmed this. The homes medication systems have been very well maintained. The manager stated that only residents in the intermediate care unit have been assessed as safe to administer their own medication. A new comprehensive risk assessment has been provided for all residents who wish to administer their own medication. (This is good practice). The records of receipt and disposal of medication had been well maintained and the medication is stored securely. The homes controlled medication was checked at random and been well maintained. All of the residents who the inspector spoke with said that the staff are friendly and respectful and ensure that their privacy and dignity is maintained at all times. The expert by experience stated that she “ was most impressed by the courtesy and the care given to everyone”. DS0000035542.V352145.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, The lifestyle experienced in the home appears to match residents expectations and preferences. People are encouraged to maintain contact with family and friends and residents are satisfied with the food provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was able to demonstrate that the home provides a good range of activities and entertainment to stimulate the residents. The programme of activities is prominently displayed in the main reception area. The expert by experience stated in her report “ a giant Activities of the Month programme was in full view. Visitors and those in care were busy checking what would be on. The most popular activities were bingo, music they recognise to hum along to and arts and crafts.” DS0000035542.V352145.R01.S.doc Version 5.2 Page 14 The residents the inspector spoke with confirmed that the home does provide a variety activities although one person said that she does not always attend as she prefers to spend time on her own. Residents and a visitor confirm that visitors are made welcome in the home at any time and the refreshments are always provided. Individual residents care plans give details of how residents can be encouraged to make decisions about their daily lives. (This is good practice). There are also residents meetings where people are encouraged to express their opinions about the way in which the home is run. Minutes of these meetings were viewed during this visit. All of the residents who the inspector spoke with said that they are very satisfied with the meals provided by the home and that alternatives will be provided if they do not want the food suggested on the menu. The expert by experience stated, “ The food was praised by everyone everyones personal tastes were catered for”. Although she also noted that one person would like “more fruit crumble”. The manager agreed to look into increasing the amount of fruit crumble provided on the menu. The meal on the day the inspection was well balanced and appeared appetising. The puddings are made with sweet and low so that the residents who have diabetes could have the same puddings as everyone else. (This is good practice). DS0000035542.V352145.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The home has an accessible complaints procedure and staff are ensuring the residents are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents are given a copy of the user-friendly complaints procedure and the manager stated that staff talk to residents, when they are first admitted to Woods Court and advise them about the complaints procedure. She stated that residents are informed, that they would rather that residents voiced their concerns early to ensure that there are dealt with appropriately. The manager is now keeping records of all complaints received by the home. The records show that there have been five complaints received at Woods Court in the last 12 months, these had all been dealt with appropriately. The residents who the inspector spoke with during this inspection said that they were confident that any complaints they may have would be dealt with appropriately. DS0000035542.V352145.R01.S.doc Version 5.2 Page 16 Staff training in Safeguarding Adults is provided for all staff as part of their induction training. She has however identified that some staff require refresher training and has started to investigate how this training will be provided. The home has an appropriate Whistle Blowing Procedure a copy of which has been provided to all staff. The member of staff spoken with during the inspection was clear about her responsibility to report any possible abuse she may observe. DS0000035542.V352145.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. The accommodation is purpose built and maintained to a good standard. At the time of inspection the premises were pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the premises was completed as part of this visit. The resident stated that the accommodation is comfortably furnished and reasonably decorated. The manager has produced a plan for the ongoing refurbishment and redecoration of the home. (This is good practice). DS0000035542.V352145.R01.S.doc Version 5.2 Page 18 Three resident said that they liked their bedrooms and confirm that they could use them at any time. They said that they had been encouraged to personalise rooms with small items of furniture, photographs and ornaments the residents informed the inspector that the home is always kept appropriately clean. The expert by experience stated “ I was shown around the bedrooms each one so homely. The bathrooms, although basic, were spacious making it easy for those with little mobility and a “walker” to be independent. In fact maintaining their dignity.” “ The laundry was spotless and well-organised; likewise the kitchen.” The recently extended laundry is well equipped with washable wall and floor coverings. It was however recommended that the appropriate cosh data sheets should be displayed in the laundry area. This will ensure that the staff knows what action to take if there are any accidents or contamination involving the cleaning substances. DS0000035542.V352145.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Staff rotas provided prior to the inspection and those viewed during the week of inspection showed that adequate staffing levels are being maintained. The homes recruitment policies and practices are not always fully supporting and protecting residents. The registered person was able to demonstrate the homes commitment to staff training and development. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rotas for the week of this inspection showed that sufficient staff are being provided to meet the assessed needs of the current residents. The manager stated that they have experienced some difficulty in maintaining adequate staffing levels and consequently “ three beds have been blocked until additional staff are available”. DS0000035542.V352145.R01.S.doc Version 5.2 Page 20 The manager stated that agency staff are covering some of the staff vacancies however many of the staff supplied by the agency have worked in the home for some considerable time. The residents who the inspector spoke with said that staff are always busy but they still find time for social interaction. The expert by experience stated “ staff repeatedly checked on a couple who were somewhat unwell”. The personal records of two members of staff were assessed as part of this visit one of the records contain two satisfactory references and appropriate criminal records bureau clearance forms and a statement by the person about their mental and physical health. The other staff records did not include written references or a health declaration. The manager stated that people would not have been allowed commenced employment until these documents had been received but that they had been sent to the main County Council Offices and could not be located. The manager was advised that this information must be available on all staff personal files, so that the inspectors can assess that the appropriate checks have been completed to help safeguard the residents. The information provided by the manager shows that 63 of the care staff are qualified to NVQ level 2 or above. (This is good practice). Staff training records observed during this visit show that a considerable amount of training has been provided. The member of care staff spoken with during the inspection confirmed this. DS0000035542.V352145.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. The home is well managed and run in the best interests of the residents. Where checked the health and safety of residents and staff is promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is well qualified and very experienced. Residents staff and visitors said that the manager is very approachable and that she seeks their views about the way in which the home is run. DS0000035542.V352145.R01.S.doc Version 5.2 Page 22 The experts by experience stated, “The manager was very busy and hands-on. She quietly and efficiently responded to each request for her time or action.” Quality monitoring systems are in place however the manager has not used the information gathered to produce an annual development plan for the home. This plan would enable people to see that the comments they make are used to develop the services within the home. Staff do manage some resident’s personal money, the records were checked at random and were well maintained. The areas of health and safety checked during this visit had all been well maintained. The homes Fire records and water temperature testing records were up-todate and accurate. Regulation 37 The information provided by the registered manager prior to this inspection stated that there had been nine deaths at the home and ten admissions to accident and emergency since the last inspection. However the homes service history indicated that these issues had not been reported to the Commission for Social Care Inspection under Regulation 37. The manager stated that the deaths had been reported to the Commission for Social Care Inspection, although these had been done in retrospect and may not have been included on the homes service history at the time of this inspection. The manager was unclear which issues needed to be reported regarding residents admission to accident and emergency departments. This was discussed in detail and clear guidance given. DS0000035542.V352145.R01.S.doc Version 5.2 Page 23 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 DS0000035542.V352145.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 17 (2) & Schedule 4 Requirement A record of all persons employed at the care home must be kept available for inspection. The records must include a copy of each reference obtained in respect of the individual staff. It is required that the registered person informs CSCI without delay of any incidents listed in Regulation 37. (This requirement is outstanding from 16/11/06). Timescale for action 16/11/07 2. RQN 37 16/11/07 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 OP33 Good Practice Recommendations It is recommended that the Registered Person produce a development plan for the home based on the findings of the quality assurance system. This will enable people to see how the comments they make help to develop the service. DS0000035542.V352145.R01.S.doc Version 5.2 Page 25 2. OP38 It is recommended that the appropriate COSH data sheets be kept in the laundry so that staff are aware of the appropriate action to take if there is an accident or contamination with any of the cleaning products. DS0000035542.V352145.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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