Inspection on 16/12/05 for Woodthorne

This inspection was carried out on 16th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodthorne 21/08/07

Woodthorne 26/01/07

Woodthorne 30/06/05

Woodthorne 19/01/05

Woodthorne 29/07/04

Woodthorne 26/03/04

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Maple Lodge

Heathlands

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Woodthorne 12 Thompson Street Willenhall West Midlands WV13 1SY Lead Inspector Chris Fuller Unannounced Inspection 16th December 2005 08:30 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 Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 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. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodthorne Address 12 Thompson Street Willenhall West Midlands WV13 1SY 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) 01902 606365 01902 606365 Miss Satwant Chahal Miss Satwant Chahal Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30.06.05 Brief Description of the Service: Woodthorne is a Victorian detached property situated on the outskirts of Willenhall. It is close to local amenities. Woodthorne is a registered care home for 21 older people. The home has been extended and now includes a single storey extension to the side of the existing property. The home provides eleven single rooms and five double rooms, providing 21 in all. There are wash hand basins in all the rooms. In addition to the lounge and dining area, there is a very pleasant conservatory which overlooks the large gardens. There is ample car parking space. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This year the Commission for Social Care Inspection is making a proportional inspection based inspection against a selected number of the National Minimum Standards. The focus remains on assessing the quality of care provided through the experience and outcomes for service users, a review progress on meeting National Minimum Standards from the previous inspection and focusing on aspects of service provision that require further development, or pose the most significant risk to service users. Some standards have not been inspected on this occasion. The unannounced inspection of Woodthorne residential home was made on Friday 16th December 2005. The assistant manager was available to assist with the process of the inspection. The Inspector spoke with care staff and residents. Records and residents files were seen. A tour was made of the communal areas of the premises and some of the individual rooms. Good progress had been made with a number of the outstanding statutory requirements and plans are in place for external and refurbishment works to be done during the spring/summer of 2006. The feedback from service users was positive about both the personal care and the food provided at the home. Once again there was a relaxed and friendly atmosphere in the home with conversation and good humour between staff and residents. Maintenance and repairs are routinely reported and recorded by staff and completed in a timely manner. What the service does well: The premises offer a Victorian building with traditional features of stained glass, high ceilings offering a spacious and homely accommodation. From the lounge and conservatory and some bedrooms there is an outlook of a pleasant rear garden to view or sit in and enjoy. The home does have a number of shared rooms to offer to married couples and or those that prefer to share and enjoy the companionship of others. The staff team work well as a team and have developed good relationships with the residents and their relatives. This encourages a social and community atmosphere in the home that is warm and welcoming. Residents are encouraged to maintain their individual lifestyle preferences through choices of individual daily routines and a range of social activities and events. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: A longstanding statutory requirement is for the premises to be assessed by an occupational therapist; this is important for the health and safety of the residents, given their physical needs and the nature of the premises. The position of furniture in the lounge currently blocks a signed Fire escape route. It is of high importance that this area is made clear until the Fire Officer has been consulted and advice acted upon. The repairs and decoration of the exterior of the building have been postponed until the spring/summer 2006. A major refurbishment of the lounge / dining room and conservatory is planned. Bathrooms and shower rooms should also be considered for refurbishment. These matters are all part of an ongoing programme of repairs and development of the property to achieve the national minimum standards. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 7 The registered manager must establish a programme of regular supervision sessions to monitor care practice and provide support to staff. To facilitate this training in supervision skills would be appropriate for those supervising other staff. The home must prioritise development of a quality assurance system in the home through resident and family feedback questionnaires, monitoring of the systems and the statement of purpose by the management team. 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. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 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 Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The management must ensure all policy and procedures for initial assessment and admissions are implemented to ensure the home is able to meet the needs of residents. Information provided to residents and their relatives such as welcome pack and contracts should hold correct and all relevant information to enable potential residents and their relatives to make informed decisions. EVIDENCE: A sample of residents files were seen and found to be generally in good order with a front index for easy reference. All residents have received Contracts from the Local Authority and /or Terms and Conditions issued by the home. At the previous inspection the records seen did not detail the Room No’s and this matter had not yet been adressed. The room no. had been included on the review of the care plan however it also needs to be recorded as part of the contract agreed. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 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 the following standard(s): 7,9 and 10 The improved care plans and an effective keyworker system ensure that the health, personal and social care needs of each resident are met. EVIDENCE: Residents files were found to be well organised and those seen had been updated with a new care plan format. Risk assessments had been completed and were comprehensive. A personal profile was produced from history provided by the resident, relatives and visiting professionals. The assistant manager had picked up through an audit of files that more information was needed at the time of initial assessment to provide a comprehensive picture of the residents needs. Progress has been made with a review and update of individual care plans with the involvement of residents and their relatives ensuring their wishes and preferences are respected. Where possible residents are encouraged to sign the care plan. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 11 The administration of medication was not observed on this inspection. However the assistant manager confirmed that four staff had completed accredited training through Wolverhampton and a further seven were due to enrol in January 2006. The assistant manager confirmed that the use of commodes had been reviewed throughout the home and five residents chose not to have a commode but use other amenities. The use of commode is assessed at the time of admission and reassessed at the time of reviews. Those residents spoken with confirmed that they found staff to be friendly and helpful. A key worker system encourages consistency of care and confidence in residents that any concerns or things they would like doing will be attended to. Records of personal care and health care were detailed and included the feelings and choices of residents. Staff said residents are encouraged to keep their independence and some still go out to the shops or clubs on their own or with relatives. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14 and 15 There is a friendly and relaxed atmosphere in the home. Staff take time to check out individual choices of residents and encourage residents to keep up their social relationships in the home, with relatives and events in the wider community. EVIDENCE: The assistant manager confirmed that the home has a budget for activities and outings. Two members of staff have been delegated responsibility for organising activities and events. The residents spoke of the different themed events the staff organised and with suitable decorations, music and meals to reflect the occasion being celebrated. The residents have a wide range of individual needs and abilities. Whilst the majority of residents were elderly requiring some assistance with personal care needs; a number had sensory impairments, some were wheel chair users, some were diagnosed with dementia and a few were still semi independent. The staff should review the activities provided and include some that address the sensory and cognitive needs of the residents. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 13 On the day of the visit the home was busy with a lot of visitors to and fro. Some took relatives out for the day. Some of the residents regularly go out for a walk to local shops. Budgets have also been provided for the cook and the maintenance costs. The cook has set up a four week rota of menus which offer a choice of meals and caters for a wide range of diets and tastes. The choice of residents is recorded and of the meals provided. There are six residents that have a diabetic diet, their details are clearly highlighted on the record of preference. Personal records hold details of nutritional reports including nutritional screening, allergies, religious requirements, weight and likes and dislikes. The cook had completed the Intermediate Food Hygiene Certificate. Records for food, fridge and freezer temperatures are completed daily by the cook. The equipment in the kitchen was all in working order. A new food probe had been provided. A new washable sealed floor covering, additional cupboard space and decoration freshened the kitchen and improves the hygiene of the area. There are two cooks that cover the week. There is good communication between them and they share workloads of cleaning rotas etc. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 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 the following standard(s): 18 The home has policy and procedures for the Protection of Vulnerable Adults. Staff have a knowledge and understanding of the signs and symptoms of abuse and would report any concerns appropriately to ensure that residents are protected and kept safe from harm. EVIDENCE: The policy and procedures for the Protection of Vulnerable Adults are held in the main office and readily available to staff. Staff complete training in Adult Protection Awareness and most have covered modules in the NVQ training. Staff are expected to report any concerns to their line manager and action would be taken in line with Walsall Adult Protection Procedure. There have been no incidents reported during the past inspection year. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 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 the following standard(s): 19,20,22,24 and 26 The home employs a maintenance person and has a programme of ongoing repairs, replacement, decoration and maintenance of the premises and grounds. Priority is given to the health and safety issues in the home. There is a gradual upgrading of the facilities with a few matters outstanding. It is important these are addressed to provide a safe and comfortable environment for residents. EVIDENCE: There is an attractive garden with a patio area; overlooked from some of the rooms, the lounge and the conservatory. Improved storage space for garden equipment and cleaning products has tidied the area and protects equipment in bad weather. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 16 There is a maintenance person available for immediate repairs and planned work. A record is kept of work completed and when the repair was identified. The assistant manager confirmed there are regular checks of hot water outlets and Legionella programme of testing. Other regular checks have been completed such as the five year electrical certificate. It was acknowledged the bathroom / shower room facilities need to be refurbished and these are to be included in the annual development plan. The home does have some basic equipment such handrails and grab rails in the home. However the registered manager has failed to arrange for an assessment of the premises by an occupational therapist who would advise on any equipment or improvements that would benefit residents at the home. Communal areas of the home looked cheerful and attractive and residents said they liked the curtains and decoration in the home. The assistant manager stated some of the easy chairs have been replaced in consultation with the respective resident. A Loop system has been provided in the main lounge to assist those with a hearing impairment. The Fire safety issue of seating, blocking the Fire Exit, in the lounge had not yet been addressed by management. Assurances were given that the fire officer would be consulted on this matter. The carpets in the hallways, communal areas and some of the bedrooms are stained and worn and need cleaning and or replacing. Generally the home was maintained in a clean and pleasant condition with no offensive odours. Laundry is completed by care staff. Night care staff complete the ironing. Facilities and equipment were satisfactory and in working order. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 The management team have made good progress in all aspects of staffing recruitment procedures, staff files, supervision and training. This needs to be regularly reviewed to ensure all aspects are maintained and ensure the development of able and competent staff. EVIDENCE: There were a sufficient number of staff on duty on the day of inspection. The assistant manager confirmed there were usually four staff on duty at peak times. At the present time there is one staff vacancies for a night care worker applicants have been interviewed and due to appoint. Recruitment records in the home have improved and the management follow a robust system of recruitment. The stability of the staff group provides continuity of care for the residents. The home has a trainee working at the home four days per week. The trainee provides no personal care or lifting and handling. Staff have enjoyed the NVQ level 2 training and some intend to progress to Level 3. The shared training experience and knowledge base has provided the staff team with a common knowledge base for good care practice. Ninety five percent of the staff are enrolled or completing their qualification working towards meeting the staffing ratio of 50 qualified. This is excellent progress for the staff team and the home. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 18 The management have established a programme of training for the safe working practice topics those still to be provided are Infection Control and the accredited safe handling and administration of medication. The registered manager and the assistant manager are also attending relevant training in line with their duties and responsibilities. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36,37 and 38 There has been progress in the operational management of the home. The benefits of improved management and staff working relationships are seen in the progress made in the delivery of care provided to residents and the cheerful and pleasant atmosphere in the home. EVIDENCE: The management are developing a quality assurance system with feedback questionnaires for residents, relatives and visiting professionals. There is a process for monitoring care practice at the time of review of the care plans. The assistant manager has begun to make night visits to complete spot checks of night care practice. The management are working with the cook to complete an audit of the kitchen and provision of meals. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 20 An annual maintenance plan has been produced and this will be developed or incorporated into an annual development plan for the home detailing all aspects of the service. A sample of residents monies were seen to be appropriately administered with current, correct records of monies held. Receipts are kept and an audit of finances completed. The majority of residents or their relatives manage their own financial affairs. The management set a programme of regular supervisions sessions for all members of staff. There are two staff due to have supervision this month; a written record is kept of supervision. One new member of staff had been issued the TOPPS induction pack and progress with this will be monitored. Administration and record keeping had improved at the home with resident and staff files being organised in good order and presented for information to be readily accessible. The home does have part time administration support for the staff wages/contracts, residents contracts and the home’s business accounts. The safe working practice topics are being addressed through training for staff and implementation of policy and procedures. Annual and other maintenance checks are being completed such as Legionnaires testing, renewal of the nurse call system, PAT testing and the Five yearly electrical certification. Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 21 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 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 2 X 2 X 2 X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 3 3 Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 22 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 2.2 Regulation 5(1)(b) Requirement Update Terms and Conditions / Contract to include Room No’s. Issue to all service users. Timescale of 31/07/05 not met The registered person/manger must provide opportunities for stimulation through activities with particular consideration given to people with dementia, and those with visual and hearing impairments. Timescale of 31/12/04 not met Consult the Fire Officer regarding the Fire Exit arrangements in the main lounge ensuring Fire Exits are kept clear at all times. Timescale of 30/06/05 not met Clean and or replace carpets. Timescale of 30/09/05 not met The registered provider must ensure that an Assessment of the premises and facilities is undertaken by a suitably qualified person including a qualified Occupational Therapist. Timescale of 2002 not met. Timescale for action 31/01/06 2 12.3 16.3 31/01/06 3 19.5 23(4) 15/12/05 4 5 20.7 & 24.4 22.1 16(1) & 23(2) 16(1) & 23(2) 31/07/06 31/07/06 Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 23 6 30.2 12 & 18 7 33.1 24 Ensure the Assistant manager 31/07/06 completes the management qualification and training relevant to the post including Supervision Skills. Timescale of 30/09/05 not met Provide an effective quality 30/04/06 assurance and quality monitoring system to measure success in meeting the aims, objectives and statement of purpose of the home. Timescale of 30/09/05 not met 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 7.4 Good Practice Recommendations It is recommended for good practice that a six monthly review is offered and held for all private residents with their relatives and for others where the statutory review has not taken place. The registered person/manager should ensure the bathrooms and shower rooms are refurbished. The registered person should provide an assisted bath on the first floor suitable to meet the assessed needs of residents. 2 21.4 & 22.4 Woodthorne DS0000033323.V271723.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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