Inspection on 10/07/07 for Woodside View

This inspection was carried out on 10th July 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 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 View 13/06/06

Woodside View 23/01/06

Woodside View 02/06/05

Woodside View 24/08/04

Woodside View 29/04/04

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Woodside View 2 Highview Caterham Surrey CR3 6AY Lead Inspector Mary Williamson Unannounced Inspection 10th July 2007 10:20 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 Woodside View DS0000013371.V342286.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. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodside View Address 2 Highview Caterham Surrey CR3 6AY 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) 01883 346313 01883 341153 Care Homes Of Distinction Ltd Post Vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2006 Brief Description of the Service: Woodside View Nursing Home is a converted Edwardian Manor House providing accommodation and nursing care. The home can accommodate up to 26 older people. This comprises of 18 single rooms, 8 of which have en-suite facilities. The home has 4 double rooms, one of which has an en-suite facility. The price range of these rooms is from £550 - £750. Residents have a choice of communal areas with a large main sitting room, a conservatory area and a dining room. The upstairs accommodation is accessed by passenger lift. The top floor is allocated to staff accommodation. The home also has a basement, which houses the central heating boiler, freezers, and store- room. The home has limited parking to the front of the house. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection took place over five and a half hours. Mary Williamson, Regulation Inspector carried out the inspection. The Provider Mr Coomb was present for most of the inspection and the administrator was present for the duration of the inspection. The home has changed ownership since the last inspection and was formerly known as Woodlands Nursing Home. The home was registered in December 2006. Currently there is no registered manager in post. However the Provider stated that he had appointed a home manager who is due to commence employment on 30/07/2007. A tour of the premises took place and records relating to the care of the residents and the management of the staff were examined. It was possible to meet all the residents and to talk with them, some in more detail than others. It was also possible to meet with the visitors in the home. Staff were occupying most of the residents in the lounge. Some residents were reading, and others were enjoying their own company in their rooms. Discussions were held with staff regarding the care of the residents and the training they had undertaken. They were all aware of their roles and responsibilities. The provider submitted an Annual Quality Assurance Assessment (AQAA) prior to the inspection, which was informative. The Commission for Social Care Inspection would like to thank the management team residents and staff for their hospitality and help during this inspection. What the service does well: The service provides a good standard of care for the residents living in the home. The care plans in place outline in detail the care provided, and includes physical, emotional, cultural, and diverse needs of residents. These are well maintained and reviewed frequently. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 6 Residents and visitors stated that they are pleased with the care provided. The arrangements in place to meet health care needs are satisfactory and residents can see their GP whenever necessary. A chef, who has been in post for several years, manages the catering arrangements. He has a good understanding of nutritional needs of the elderly. Several residents made positive comments about the food, saying, “the food is good here” and “the food is delicious”. Health and safety are promoted with staff undertaking all mandatory training. What has improved since the last inspection? What they could do better: The home has developed considerably since the last inspection and the ongoing programme of refurbishment continues, with the provision of a treatment room being identified to enhance privacy and confidentiality. The building continues to be upgraded and the roof is currently being repaired. The standard of record keeping is generally satisfactory. However resident’s contracts of occupancy need to be retained in the home and all residents should be issued with one on admission to the home. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 7 The staff employment files are not well maintained and the recruitment procedure should be revised, to include all the necessary employment documentation as required by employment legislation. This is also necessary to protect the residents in the home. In the absence of a registered manager senior staff in charge should attend the local authority training on safeguarding vulnerable adults, in order to protect residents in their care. 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. Woodside View DS0000013371.V342286.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 Woodside View DS0000013371.V342286.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): 1, 2, 3, and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have access to sufficient information in order to help them make a choice about living in the home. Needs assessments and contracts are in place. The home does not provide intermediate care. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. All prospective residents and their relatives have access to a copy of these in order to help them make an informed choice about the home and if they wish to live there. These documents have recently been updated. The inspector asked to sample three contracts of occupancy. These were not available in the home and the provider had a selection of contracts faxed from head office for inspection purposes. A discussion took place between the provider and the inspector regarding contracts being retained in the home, which must be signed and dated. All prospective residents have a needs assessment undertaken prior to admission. Four needs assessments were randomly sampled. These were informative and well maintained. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 10 The provider was out undertaking a needs assessment when the inspector called, but arrived in the home soon after the commencement of the inspection. The provider is not a nurse, or a social care expert but informed the inspector that an experienced staff member from his other home accompanied him to undertake the assessment. The home does not provide intermediate care. Woodside View DS0000013371.V342286.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, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care needs are identified in individual care plans. Appropriate arrangements are in place to meet the health care needs of residents. The medication procedure in place protects the residents living in the home. EVIDENCE: Individual care plans are in place and four of these were examined. The care plans are well written based on information gathered from the pre admission needs assessment, input from the resident whenever possible, information obtained from relatives, reports from care managers and any other relevant information. These are reviewed regularly by staff and updated when necessary. A care manager undertakes annual reviews of care where appropriate. Risk assessments are included in care plans, for example manual handling assessments, falls analysis, skin care assessments and a nutritional risk assessment. The arrangements in place to meet the health care needs of the residents are satisfactory. All residents are registered with local GPs. One resident has Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 12 retained her own GP following admission to the home. GP visits are arranged when necessary. The chiropodist visits the home every two weeks. Domiciliary dental treatment and optical treatment are also provided. The local Dean Hospital is accessed for audiology, X rays and minor medical procedures. The home has a medication procedure in place, and all staff administer medication in accordance with this policy and The NMC (Nursing and Midwifery Council) Code of Professional Conduct. Boots the chemist supplies the medication for the home mainly in blister pack format. They also undertake regular audits of medication. The last audit was undertaken on 06/06/2006. Boots also provide training for staff. Medication recording charts were seen and these are well maintained. Currently there are no controlled drugs in use in the home. There is a list of homely remedies and a list of staff signatures retained in the medication folder. Privacy and dignity are observed and staff were seen to knock on bedroom doors prior to entering. Screens are provided in shared rooms. Staff interact with residents in a polite and respectful manner. Residents can see their visitors in the privacy of their own bedroom. They can also see the doctor in their rooms. The provider explained that a room had been identified and would soon be converted into a treatment room where residents can see health care professionals in private. Woodside View DS0000013371.V342286.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, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to participate in leisure activities. Family links are maintained. The nutritional needs of the residents are met. EVIDENCE: The home has an activities programme in place, which includes music and exercise, reminiscence therapy, manicure, board games, card games, and a weekly film show. It was possible to talk with the activities coordinator during the afternoon. She explained how her activity programme for that afternoon was specifically planned for the residents with dementia and included one to one reading sessions, one to one talks, and hand massage. Residents were observed sitting in the lounge reading the daily newspaper and watching the television. One resident was listening to classical music, while another was accessing the garden for a cigarette. The provider stated that more staff hours were planned to expand the activity programme. Family links are maintained and visitors are welcome in the home at any reasonable time. Friends visiting during the inspection stated that the home was most welcoming and that they were impressed with the care provided. Relatives are encouraged to take part in the care planning process. They are also welcome to attend reviews of care. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 14 The staff stated that residents are supported to make choices regarding how they spend their time, when they get up and go to bed, and the clothes they wear. Cultural and social requirements are included in individual care plans. The kitchen was visited, which has recently been refurbished. The regular chef was off duty and it was possible to speak with the relief chef. The chef plans menus with input from residents, and knowledge of individual likes and dislikes. Nutritional assessments are undertaken and special diets are catered for. Currently no residents have cultural food requirements, but the provider stated that staff needs are catered for. Several residents stated that the food was “very nice”. Staff were observed providing sensitive support to residents who required help with feeding. Woodside View DS0000013371.V342286.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, and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure and the abuse awareness procedure in place protect the residents living in the home. EVIDENCE: The home has a complaints procedure in place and all residents and their relatives have access to a copy of this. This procedure is also included in the Service User Guide. The complaints register was seen and confirmed that any concerns and complaints received were dealt with in accordance with the home’s procedure. There have been no formal complaints received by CSCI, and any concerns have been resolved in a satisfactory manner. The home has an abuse awareness policy in place and all staff have undertaken training in their procedure during their induction training. The provider has attended Surrey’s Multi Agency training on Safeguarding Vulnerable Adults. It is recommended that a senior member of staff also attend this training in view of the current management arrangements in the home. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 16 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, 20, 21, 24, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a muchimproved environment, which is safe and comfortable. The home is clean and hygienic. EVIDENCE: The home was registered to the current provider in December 2006. Since the last inspection the provider has undertaken a major refurbishment programme in the home to comply with the requirements at the last inspection. The dining room has been fitted with a new floor and new furniture. There are also tea and coffee making facilities provided in the dining room for residents’ use. The lounge has been decorated. The main reception area has been decorated and new furniture provided creating a recreational area for residents and relatives. Most of the bedrooms have been redecorated and furnished to a good standard. These are also personalised reflecting individual personalities. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 17 The garden has been landscaped, and ramp access has been provided for residents to enjoy this facility. All the bathrooms and toilet areas have been refitted with modern automatic shower units, touch flush WCs, and assisted bathrooms. There is a new laundry located on the ground floor, which is well equipped with new washing machines and tumble dryers. Laundry staff are aware of the infection control policy in place and the management on infected laundry. Two new boilers have been provided which are also thermostatically controlled. The refurbishment programme is ongoing and currently includes the repair of the roof, the provision of a treatment room. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff on duty was sufficient to meet the needs of the residents. The recruitment procedure does not protect the residents in the home. EVIDENCE: The duty rota was seen and indicated that the number and skill mix of staff on duty was sufficient to meet the assessed needs of the current residents in the home. The home also employs a good team of ancillary staff including a chef, relief chef, kitchen assistance, housekeepers, a maintenance person, an administrator, and an activities coordinator. The recruitment procedure was examined. Three staff employment files were randomly sampled and were found to be badly maintained. These did not contain the required documentation. For example, written references were not in place for two staff and one file had no employment details. Another file had no record of a POVA check being in place while a CRB check was being undertaken. A requirement has been made accordingly. Staff training and development are ongoing with all staff undertaking induction training in accordance with Skill for Care. NVQ training is ongoing and two staff are undertaking NVQ level 2. The training company used is Corporate Image facilitates NVQ training and some staff have enrolled to do NVQ level 3. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 19 Mandatory training includes manual handling, life support training, infection control, fire safety, food hygiene, dementia awareness, abuse awareness and health and safety. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 20 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, 37, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements in the home are temporary but satisfactory. The home is run in the best interest of residents and promotes safety. EVIDENCE: The provider stated that he has appointed a home manager who is due to commence employment on 30th July 2007. Meanwhile the provider has satisfactory management cover in place to protect resident’s wellbeing. There is a registered nurse supervisor in post who undertakes the management responsibilities. She has the support of the provider who has twenty- five years experience as a provider of care and has an NVQ level 4 in management. There is also an administrator in post. Quality monitoring systems are in place to measure quality assurance. Survey forms are distributed to residents, relatives, health care professionals and the Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 21 information gathered analysed and acted upon. Thank you letters and compliments are also filed for information. The home does not handle financial affairs for residents, and no member of staff acts as appointee on their behalf. There is a wide range of health and safety policies and procedures in place and a selection of these were sampled during the inspection. All staff undertake health and safety training and COSHH procedures are observed. Fire safety arrangements are satisfactory. The fire alarms are tested weekly and recorded. There is a contract in place for the maintenance of fire fighting equipment and emergency lighting. All staff attend yearly fire safety training, which is recorded in their training files. Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 2 3 X X N/A 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X X 3 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 3 X 3 X 3 X 2 3 Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 OP37 Regulation 5(1)(b) Requirement The registered person must ensure that a copy of the terms and conditions of occupancy is provided to the resident outlining the accommodation provided and the fees payable and the method of payment. A copy of this must be retained in the home for inspection. The registered person must ensure that all senior staff in charge of the home have attended the Local Authority training in Safeguarding Vulnerable Adults, in order to protect them from harm and abuse. The registered person shall not allow staff to work in the home unless he has obtained all the required documentation as listed in Schedule 2 in order to protect the residents living in the home. This documentation must be available in the home for inspection at all times. Timescale for action 17/07/07 2 OP18 13(6) 17/07/07 3 OP29 OP37 19(1)(b) 17/07/07 Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodside View DS0000013371.V342286.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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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