Inspection on 01/09/05 for Woodside Resource Centre

This inspection was carried out on 1st 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

Woodside Resource Centre 27/01/09

Woodside Resource Centre 08/02/07

Woodside Resource Centre 14/02/06

Woodside Resource Centre 03/11/04

Woodside Resource Centre 13/08/04

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

CARE HOMES FOR OLDER PEOPLE Woodside Resource Centre Cavendish Road Middlesbrough TS4 3DJ Lead Inspector Jackie Herring Unannounced 1 September 2005 10:00 am st 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. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodside Resource Centre Address Cavendish Road Middlesbrough TS4 3DJ 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) 01642 828146 01642 827418 admin.heatherbrook&careuk.com Care UK Community Partnerships Ltd Mrs Karen Morrison Care Home 60 Category(ies) of DE(E) Dementia - over 65 (60) registration, with number of places Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 3/11/04 Brief Description of the Service: The Willows is a 60 bedded purpose built home which was registered in November 2002. It comprises of two distinct units; a 40 bedded nursing unit for individuals over the age of 60 who have dementia and a 20 bedded unit for personal care the same category of care. Within the 20 bedded unit, 5 of the beds provide a dedicated respite service. A number of the nursing beds are also dedicated for continuing health care. All of the 60 rooms are single with ensuite facilities and meet the room requirments. The home is situated in an urban setting within ready access to local transport, the local hospital a public house and a church. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection and was carried out over one and a half inspection day, twelve inspection hours in total. Residents, staff and relative interviews were undertaken and there was indirect observation throughout the inspection days with staff and resident interactions being noted. Time was spent throughout the inspection walking around the home and informally chatting to people. I should be acknowledged that many of the residents have severe dementia and due to cognitive and communication difficulties it was not possible to seek the view of a substantial number of residents during this inspection. What the service does well: What has improved since the last inspection? Changes have been made to the resident’s records keeping, which allow for more comment and detail. These will be examined further at the next inspection. The medication record keeping has improved with all appropriate records now in place. Some carpets have been replaces as part of the ongoing refurbishment programme. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 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 Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 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) None of these standards were examined during this inspection. EVIDENCE: Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 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) 10 The staff have a friendly and respectful approach to residents and individuality and rights are respected. EVIDENCE: Whilst individual residents records were not examined in detail, there was detailed discussion with the manager. The records are in the process of being computerised and in depth training is underway for all of the staff, who are involved in residents records. The system was demonstrated and it was confirmed that the assessment documentation allowed for additional comments on individual assessed needs and was no longer a tick box. The individual resident records will be examined further at the next inspection. One relative said, “I am happy with how my mother is being cared for, I am kept fully informed about any changes, when the GP visits etc”, her mother stated, “they are wonderful, marvellous”. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 10 Residents, relatives and staff were involved in discussion about life within The Willows. One resident said, “I am treated with dignity and respect, the staff are very friendly”. Relatives said “The staff are friendly, the use the correct tone, they are polite and respectful and kind”. Staff also discussed the importance of treating residents with dignity and gave some examples such as handling personal care needs with discretion. Although the medication systems were not fully examined, it was confirmed that there are now records in place to evidence all medication that has been ordered. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 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, 14 Residents’ daily lives are flexible and very much determined by individual needs and choices. Reviewing the activity arrangements within the home may further enhance quality of life. Open visiting is encouraged and residents are able to maintain contact with family and friends. EVIDENCE: Time was spent within the residential and nursing unit across the two inspection days. Residents within the residential unit were able to be involved in informed discussion about life within The Willows. They said, “This is a nice place to be, it is relaxed and calm and is very, very friendly”, “It’s just like being at home, you have a normal day, you have companionship, it’s lovely and there is a nice lot of people”, “If you want to go to bed you can, there is always someone to talk to”. It was also confirmed that there were regular visitors some of who spoke with the inspector, they said, “We feel like it is just like a family, like being with friends”. Staff said that the routines of the home were developed around individual residents needs and were very flexible. One relative who visits on a very regular basis stated, “It’s not regimented, it’s flexible”. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 12 The residents who live within the nursing unit at The Willows have more severe cognitive and communication difficulties due to their dementia and it was not possible to engage residents in discussions about their lives. Through observation during the inspection and discussion with relatives, staff and the manager it was clear that the resident’s needs were intimately known by all and positive staff/resident interactions were observed. Staff spoke about the importance of individuality and demonstrated knowledge of the residents they cared for. Staff talked about the flexibility of life for residents, the importance of individuality and that need to ensure rights are considered. During a number of discussions about activities and recreation with residents, relatives and staff, people thought that there could be more activities. There was a perception from staff within the nursing unit that the activities coordinator spent more time in the residential unit. A small number of residents said they would like the opportunity to go out of the home more often. Relatives said that they thought there could be more stimulation although other people thought that there was quite a good range of activities. A staff member in the residential unit described quizzes, bingo, entertainment and monthly input from an external organisation called Motivation. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 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) 16, 18 A clear complaints procedure is in place and complaints are handled objectively; procedures are in place to protect residents from abuse. EVIDENCE: Residents who could be engaged in discussion stated that they had no worries or concerns. Relatives said they were aware of the complaints procedure and said they would speak to the key staff in the first instance and had every confidence that any concerns would be appropriately addressed. The complaint procedure was observed to be on display throughout and contained the required information. During discussion with the it was confirmed that complaints were managed in a thorough detailed complaints records were made available for examination, contained detailed information. the home manager, way and and they Staff were aware of abuse and what constitutes abuse and they had received training on this topic as well as Protection of Vulnerable Adults. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 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, 20, 26 The Willows is generally clean and warm offering residents a homely environment in which to live. However a number of areas are in need of refurbishment, which will enhance the environment for the benefit of the residents. EVIDENCE: Time was spent walking around both of the units during the two inspection days. The residential was observed to be clean, well maintained, well decorated and homely. The nursing unit was in need of some refurbishment as a number of the carpets were looking a little worn, such as corridors and the small lounge, as were some of the chairs. Through discussion with the manager, it was confirmed that a refurbishment plan had been implemented and carpets had recently been replaced in two of the lounge areas. The manager informed the inspector that the chairs were going to be replaces as part of the major refurbishment programme due to commence in November 2005. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 15 Specialist chairs were also observed to be in need of attention as they were ripped. On the second day of inspection, the manager confirmed that new chairs had been ordered. It was also agreed that there was the need to review the locking mechanism of the bathroom/shower room doors, as the current system of using an external bolt is not acceptable. On the second day of the inspection alternative mechanisms were in the process of being tested and the manager said that they would be installing a suitable alternative. The dining room in the nursing unit continues not to be the most conducive environment due to the size. It is acknowledged that plans are underway to improve this environment with the installation of a partition. The staff team believed that this would be an improvement and thought that it would have an improvement on the quality of mealtime activity for residents as the current mealtimes are very noisy. This plan of action was also detailed within Regulation 26 visit reports. The manager also informed the inspector that plans were also underway to improve the residential units garden and also the centre courtyard garden. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 16 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 Whilst the staffing levels and skill mix within the home is sufficient to meet the needs of the residents, the way in which supervision and observation takes place within the nursing unit should be reviewed to further enhance the existing system. Staff are well trained and competent to meet the needs of the residents. EVIDENCE: The staffing levels with The Willows exceeds the minimum staffing agreement and the staff team generally felt that there was sufficient staff on duty to meet the residents needs. One staff member said of the nursing unit, “It’s a hard unit to work, however enough staff to meet the needs of the residents”. Within the nursing unit, staff described how they rotated around the unit and the benefits of always working in tandem with another member of staff. Staff thought this was essential due to the high dependency needs of residents. There were some mixed views expressed by relatives of the staffing levels within The Willows, no concerns was raised regarding the residential unit, however a number of relatives raised concern about the visibility of staff within the nursing unit. Relatives stated that there were occasions when lounges were left unsupervised for quite some time. This matter was discussed immediately with the manager during the inspection and the manager then had spoke to the relatives. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 17 The inspector did observe staff walking around the unit completing observation sheets. Through discussion with the manager it was agreed that the way in which staff supervised and observed the residents, particularly in the lounge areas would be reviewed with a more pro-active approach being taken and more direct discussion and communication with residents and relatives. It was confirmed through discussion and observation that the appropriate skill mix is in place, with Senior Care workers in charge of the residential unit and two qualified nurses, one of which is a Registered Mental Nurse on duty at all times within the nursing unit. During discussion with relatives they said, “The staff have a very understanding approach, I feel they have been well trained”. Staff said that the organisation was very good at providing training for them. They confirmed that they received their entire mandatory training, NVQ training as well as client specific training such as Dementia Care awareness. The manager informed the inspector that 70 of staff were trained to NVQ level 2 or above and that further staff had been enrolled. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 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) 31, 32 The resident’s benefit from a well run, well managed home. EVIDENCE: During discussion with residents, relatives and staff, they said that The Willows was a well run and well managed home. Relatives said, “Happy with the unit, it runs well”, “I think it is great here”. Staff made positive comments about the management of the home and said, “This is the best home I have worked in, the staff are looked after as well as the residents, views are listened to”, “I feel valued, the manager is fair”, “Definitely supported, the manager is always helpful and feel comfortable to take any concerns to her”. The manager has the required experience and qualification for this role. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 2 x x x x x 3 STAFFING Standard No Score 27 3 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 3 x 3 3 3 x x x x x x Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 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 OP19 Regulation 23 Requirement A number of carpets must be cleaned or replaced. A number of the standard lounge chairs must be cleaned or replaced. Two of the specialist chairs must be repaired or replaced. Alternative arrangments must be implemented for the locking of bathroom/shower room doors. The planned work to improve the environment within the nursing unit dining room must be completed. (This is an outstanding requirement from 31 January 2005). Timescale for action 31/12/05 2. OP20 23 31/12/05 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 OP12 Good Practice Recommendations Consideration should be given to reviewing the activity B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 21 Woodside Resource Centre 2. OP27 arrangements within the home. The system for observation and supervision of the lounge areas within the nursing unit should be reviewed with a view to enhancing the current system further. Woodside Resource Centre B51-B01 S33593 Woodside V228630 010905 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale, Stockton-on-Tees TS17 6QX 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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