Inspection on 10/02/06 for Woodthorpe Manor Care Home

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodthorpe Manor Care Home 16/08/06

Woodthorpe Manor Care Home 05/01/05

Woodthorpe Manor Care Home 20/09/04

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 Woodthorpe Manor Care Home Egerton Road Woodthorpe Nottingham NG5 4FF Lead Inspector Karmon Hawley Unannounced Inspection 10th February 2006 10:45 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 Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 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. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodthorpe Manor Care Home Address Egerton Road Woodthorpe Nottingham NG5 4FF 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) 0115 9206021 0115 9206021 Mr Chabilill Beekarry Mr Beelall Patroo Mrs Floris Patroo Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (28), Terminally ill (2) of places Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 2 registered nurses and 4 care staff on day duty 1 registered nurse and 2 care staff on night duty Date of last inspection 08/09/05 Brief Description of the Service: Woodthorpe Manor is a care home providing personal care and nursing care accommodation for 28 older people and 2 terminally ill. It is owned by Mr Beekary and Mr Patroo and managed by Mrs Florence Patroo. The home is located in Woodthorpe an inner city area of Nottingham, close to the local shops, pubs, general practitioners surgery and other amenities. It is easily accessible by major roads and a bus link into the city is available at the end of the road. The home is an extended residential house, which consists of three-storeys. The home has two lounges, and a separate dining room. The home has 12 single rooms, of which 8 have en-suite facilities and 5 double rooms. There are three bathrooms, two of which are fitted with a bathing hoist and two shower facilities. There is a passenger lift. The grounds are well maintained and offer a relaxing environment. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in four and a half hours and was performed by one inspector. The main method of inspection was case tracking, this is a method of sampling the records of three randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Five service users and two relatives were spoken with and so as to give the inspectors an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The manager assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate a good understanding of service users needs and the core values and principles in relation to their job role. The focus of this inspection was to concentrates on the remaining core standards not assessed and the requirements made at the previous inspection. What the service does well: Service users and relatives spoken with spoke highly of care received and life within the home, stating it was splendid, food marvellous and staff were very kind and respectful. A caring ethos was prevalent throughout the home and staff were observed to interact well with service users and relatives. The home is well maintained and the future development plans discussed reflected the thought and consideration that goes into this process, thus acknowledging the importance of a comfortable quality of life for service users living the home. Staff spoken with were able to demonstrate an understanding of whole person needs and the importance of facilitating these. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 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 Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 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): 3 Service users may be assured their needs will be assessed and met prior to entering the home. EVIDENCE: The requirement set at the previous inspection was met. The preadmission assessment now covers the requirements of the standard. Evidence of this taken place was available within case files examined. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 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): 7,9,10 Service users health, personal and social care needs are set out in a plan of care, however although improved further development with regards to risk assessments are required to ensure service users are fully protected. Service users are protected by the home medication policies and procedures, however to ensure they are fully protected minor improvements are required. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Service users undergo various assessments with regards to the activities of daily living, whole person needs, nutrition, pressure area care and continence. Information gained forms the basis of the plan of care. Care plans in place were personalised, reflected service users identified needs, choices and preferences. Daily records were maintained; these were in depth and reflected significant events, care received and changes in condition. Risk assessments were in place for the majority of risks identified, however one risk in two plans of care were not identified and a management plan in place. Consent forms with regards to the taking of photographs within one service users file had not Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 11 been completed, however a photograph of this service user was attached to the file. Care plan agreements are currently being formalised, one file observed had this form completed to reflect that the service user and relevant others had been involved in the plan of care. The two files where this had not been completed however demonstrated by the information gained that service users had been consulted. Service users spoken with stated that their needs were fully met and they were happy with life within the home. staff were able to discuss service users needs and how these are met within their job role. Appropriate policies and procedures with regards to medicines are in place and arrangement for the return of medication has been rearranged to ensure the new legislation is complied with. Medication charts were clear, however these were handwritten and did not have two signatures in place to ensure these are correct. The manager carries out audits and regular supervision of staff to ensure they remain up to date in their knowledge and practice. Maintaining service users rights and privacy are covered within the induction programme and during staff supervision. Staff are instructed to knock on doors prior to entering and all double rooms have screening in place. Visitors and consultations can be conducted in private should this be required. Telephone facilities are available for service users should it be required. Service users spoken with stated that staff were always respectful and their privacy was maintained. Staff spoken with were able to discuss the core values and principles. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 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): 15 Service users receive a wholesome appealing balanced diet in pleasing surroundings. Further consideration with regards to the recording of temperatures is required to ensure service users are fully protected. EVIDENCE: The kitchen was clean and tidy on the day of the inspection, appropriate cleaning rotas were noted to be in place. The menu on offer was nutritious and balanced, although there is only one main course offered at lunch time alternatives are available should the main course be disliked, there was evidence of this occurring as records of meals service users had taken were held, service users were also able to substantiate this and this was observed as the main meal was served. Specialist diets are also catered for, one service user spoken with discussed her needs and how they were met. Records were maintained as appropriate with the exception of temperature recording, there were gaps in the fridge, freezer and food recordings, the cook stated this had occurred when she was not on duty, the manager confirmed it was when a kitchen assistant had cooked that day. Food temperatures were noted only to be recorded when a roast dinner is prepared; a chicken dish had been served which has not been probed. Service users spoken with stated food was marvellous, at a high standard and plentiful. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 13 Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 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): 16 Service users and relevant others may be confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: A complaint had been received a few days prior to the inspection taking place, the manager had acted appropriately with this regard and investigations had commenced. Due to the nature of the allegation made by a service user the manger was awaiting an official complaint so as to commence adult protection procedures if required. On the day of the inspection the relatives and the service user who had made the allegations were spoken with. The relatives’ spoke very highly of the staff and the care offered, they expressed no concerns; the service users spoken with also expressed no concerns. Following the meeting an action plan was implemented to ensure appropriate policies are followed and the service users receives additional care required to meet her current needs. Service users spoken with stated they were fully satisfied with the home and care received, one stated the home was splendid. Staff spoken with were able to discuss how they would deal with a complaint should it be received. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 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 Service users live in a safe, well-maintained environment. EVIDENCE: A routine maintenance programme is in place. The home has continued to develop over the last six months and was considered to be well maintained. Further development plans are also in place. There are sufficient domestic staff employed to maintain the cleanliness of the home and the home was clean and tidy on the day of inspection. One recommendation was made during the previous environmental health officers visit, the manager stated this had been complied with. No report had been received by the home. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 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 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): 28,29,30 Service users are in safe hands and staff were able to demonstrate competency, however further attention is required to ensure staff are trained in all mandatory areas in order to fully protected and meet service users needs. Service users are supported and protected by the homes recruitment policies and practices. EVIDENCE: Four members of staff have completed the national vocational qualification level 3 and two staff members have commenced level 2. Four domestics have attained level 1 and one staff member is working towards level 1. An induction programme is available for all new staff; there was evidence of the old style induction programme used within one staff file examined. A new induction programme formulated by Mulberry house is now being implemented. The requirements set at the previous inspection with regards to ensuring all required records are on file and registered nurses professional identification numbers was observed to have been met. The manager stated that in house training has not been fully implemented due to the development of the home, however it is intended that this will now take priority to ensure staff receive training required. On examining training records these demonstrated that the majority of staff training with the exception of fire training and food hygiene was out of date. The manager and another member of staff have attended the protection of vulnerable adults and it is the intention to cascade this to other staff. Staff spoken with stated they felt supported in Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 17 their job role and confident in carrying out their duties, however feel they would benefit from further training. Service users spoken with stated that they felt confident in the fact that staff were able to meet their needs. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 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 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): 31,33,35,38 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 her responsibilities. Further consideration has been given to quality assurance monitoring, this now requires fully implementing to comply with the previous requirement. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected, however further consideration with regards to fire alarm testing, temperature recording, risk assessments and staff training is required to ensure service users are fully protected. EVIDENCE: The manager is a registered nurse and has attained a postgraduate management degree and the national vocational qualification managers award. She had been the manager of the home since 1997 and therefore has the Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 19 required knowledge and skills. She intends to remain up to date in her practice via study days and training courses. Staff spoken with stated that they felt well supported by the manager and that she was approachable. Service users spoken with also spoke highly of the management of the home and felt the home was well run. A new package with regards to quality assurance monitoring has been purchased and due to be implemented. The manager carries out regular audits and checks ensuring a quality service is provided. If able service users hold their own finances and a lockable facility is available for the safe keeping of these, otherwise personal finances are not held on the premises and any costs incurred are invoiced accordingly. Appropriate maintenance and certificates were available for inspection with the exception of the portable appliance testing, however this had been arranged and was confirmed by a telephone call on the day of inspection. Water temperatures are recorded monthly, however these demonstrated that water is stored at 50 oC, the maintenance man stated this was due to mixer values being installed in stages and not all are fitted as yet, thus to reduce the risk of scalding water is stored at this temperature, a risk assessment with regards to legionellosis was not available. New booklets have been implemented with regards to staff’s responsibilities and health and safety evidence of these being used was available. The fire logbook demonstrated that all staff required further fire drills and fire alarm systems had not been tested since January 2006. Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 13(4,c) Requirement The responsible individual is required to ensure appropriate risk assessments are in place to fully protect service users. This requirement has been partly met, however requires further development to full comply. Consent must be gained prior to the taking of photographs of service users. The responsible individual is required to ensure service users are fully protected by the homes medication policies and procedures, two signatures are required for all handwritten entries on the medication chart. The responsible individual is required to liaise with the environmental health officer with regards to temperature testing/recording and ensuring the safety and protection of service users The responsible individual is required to ensure staff are trained in all mandatory areas to ensure they individually and collectively have the required DS0000026482.V282847.R01.S.doc Timescale for action 10/03/06 2 3 OP7 OP9 12(2) 13(2) 10/03/06 10/03/06 4 OP15 13(4,c) 17/02/06 5 OP30 18(1,c,i) 10/05/06 Woodthorpe Manor Care Home Version 5.1 Page 22 6 OP33 24(1) 7 OP38 24(4) 8 OP38 13(4,c) knowledge and skills to meet service users needs. A development plan is required to demonstrate how this will be achieved. The responsible individual is required to ensure records to demonstrate that quality assurance is being monitored and is available for inspection. This has been partly met and new tools are in place, further development is now required to fully comply with this requirement. The responsible individual is required to ensure staff attend fire drills and fire alarm systems are tested on a weekly basis to ensure service users are fully protected. An appropriate risk assessment with regards to legionellosis and water temperature is required to protected service users. 10/04/06 10/03/06 10/04/06 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 Woodthorpe Manor Care Home DS0000026482.V282847.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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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