Inspection on 16/08/06 for Woodthorpe Manor Care Home

This inspection was carried out on 16th August 2006.

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

Woodthorpe Manor Care Home 10/02/06

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 16th August 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodthorpe Manor Care Home DS0000026482.V307194.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. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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.V307194.R01.S.doc Version 5.2 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 10/02/06 Brief Description of the Service: Woodthorpe Manor is a care home providing personal care and nursing care accommodation for 28 older people. 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 9 have en-suite facilities and 5 double rooms. There are two bathrooms, 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. The current weekly fees which are discussed on the point of enquiry are as follows: shared room £357.50; small single £365; large single £337.50; single with ensuite £400. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and thus the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. One inspector undertook the site visit over three hours. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of four 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 were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with life within the home and care received. The manager assisted in the site visit and two members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job roles. What the service does well: A kind and caring ethos was prevalent throughout the home and staff were observed to interact with service users in a meaningful manner. Service users spoken with stated that they were well looked after and staff were friendly and respectful at all times. Staff spoken with were able to discuss the core values and principles in relation to their job roles. The issues of equality and diversity are well understood and the staff are making good progress in ensuring this is fully reflected in the ethos of the home. The home is well maintained and the plans that were discussed at the previous inspection have been carried out to a high standard. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although it is recognised that risk assessments have developed further development is required in respect of identified needs to ensure service users are fully protected. It is recommended that all staff continue to work towards completing mandatory training to evidence that staff are fully trained and competent to do their jobs. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 Page 7 It is recommended that the quality assurance systems are implemented in all areas of the home to substantiate that a quality service is being delivered in the best interests of service users. 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. Woodthorpe Manor Care Home DS0000026482.V307194.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 Woodthorpe Manor Care Home DS0000026482.V307194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users may be assured their needs will be assessed and met prior to moving into the home. EVIDENCE: The manager carries out preadmission assessments prior to service users moving into the home. There was evidence of this taking place in service users care plans. The assessment covers the requirements of the standard. Service users and relevant others may also visit the home and spend a little time there prior to making a decision to move there. One member of staff spoken with substantiated this procedure. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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): 7,8,9,10 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the home. Service users health, personal and social care needs are set out in an individual plan of care, however further development of risk assessments are required to ensure service users are fully protected. Service users health care needs are met. Service users are protected by the homes policies and procedures for dealing with medicines. 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 within one care plan observed however within two others where Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 Page 11 bedrails were in use risk assessments in regards to entrapment were not available. Consent forms with regards to the taking of photographs have now been completed in all files examined. Care plan agreements have also been formalised and were in place within files examined. Service users spoken with expressed that they were happy and settled and their needs were fully met. Staff spoken with were able to discuss service users needs and how these are met within their job role. There was evidence within service users case files to demonstrate that the multidisciplinary team and relevant specialist services are accessed as required. One service user spoken with substantiated that access to these services was available when required. Appropriate policies and procedures with regards to medicines are in place. Medication charts were clear and two members of staff now sign hand written entries. The manager carries out audits and regular supervision of staff to ensure they remain up to date in their knowledge and practice. The manager stated that staff are instructed on maintaining service users privacy and dignity during the induction process and on a continual basis. Staff spoken with substantiated this. Service users spoken with stated that staff were kind and respectful at all times and they felt listened to. One service user stated that staff knock on doors prior to entering. Visiting and consultations can be conducted in private should this be required. Staff spoken with were able to discuss the core values and principles in relation to care provided. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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): 12,13,14,15 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their needs. Service users are enabled to maintain contact with relevant others. Service users are helped to experience choice and control over their lives and feel that individuality is respected. Service users receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: The manager stated that the routine of the home was flexible and service users may choose how they spend the day. Service users spoken with substantiated this. Service users may choose when they rise and retire to bed as able, and spend the day as they please. Meals are varied and choice is offered, likes and dislikes are taken into consideration and alternatives facilitated. A church service is held monthly within the home and service users are facilitated to visit church outside the home if required. Within care plans it was evident that preferences and personal beliefs had been considered. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 Page 13 The post of activities coordinator is currently vacant, however the manager continues to attempt to recruit for this post. A physiotherapist has been employed by the home and visits three times a week offering various exercises and activities for service users. Staff spoken with stated this has been beneficial and service users are benefiting in regards to mobility. Two service users spoken with discussed how they enjoy the keep fit sessions. All service users spoken with were satisfied with the level of activities on offer. Staff also offer activities when able which include dominoes and various games. Service users have recently been on a boat trip and the manager stated that other trips are being arranged. One service user discussed how they enjoyed the walks out with staff. Visitors are welcomed into the home at any time and may be received in private if wished in the dining room if vacant or service users own rooms. One service user spoken with stated they were able to receive visitors at any time and they were always made welcome. Some service users hold a small amount of money on their person and a lockable facility is provided, otherwise relatives deal with all finances. Service users are able to bring in personal possessions and this was evident during the tour of the home as rooms were personalised. One service user spoken with stated they had been able to bring in their own belonging and had a nice room. In respect of equality and diversity staff were able to discuss how this is recognised and implemented in practice within the home. Service users spoken with stated that felt that they were treated as individuals and were respected at all times. The environmental health officer has recently visited the home, no requirements or recommendation were made. The manager and the kitchen staff have attended a study day on safer food better business and are currently implementing new documentation. A wholesome and nutritious menu was on offer and although there is only one main course on offer at lunchtime alternatives are available should the main course be disliked, one service user spoken with substantiated this. Specialist diets are also catered for as required. Service users spoken with stated that food was at a good standard and plentiful. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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): 16,18 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users and relevant others may be confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Relevant policies and procedures are in place with regards to the dealing of complaints. There have been no complaints received since the previous inspection. The protection of vulnerable adults referral that was made at the time of the previous inspection has been resolved and no further action taken. Staff spoken with were able to discuss how they would deal with complaints if received. Those service users spoken with expressed no complaints and two stated that staff listen to their needs. All staff have current criminal record bureau checks in place, these were observed in staff files and staff spoken with were able to substantiate that these had taken place. Training in respect of the protection of vulnerable adults is currently being cascaded to all staff; there was evidence within staff files that this had commenced. Staff spoken with were able to discuss issues of abuse and how they would deal with matters if they arose. One service user spoken with expressed that they felt safe at the home. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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): 19,26 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users live in a safe, well maintained, clean, pleasant and hygienic environment. EVIDENCE: A routine maintenance programme remains in place and records were available to substantiate that this takes place. Redecoration and refurbishment was evident during the tour of the home. The garden areas have been landscaped and a pleasant seating area is available. One service user spoken with stated that they enjoyed sitting in the garden. 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. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 Page 16 The environmental health officer has visited the home; no requirements or recommendations were made. The fire authority has also visited the home and again no requirements or recommendation were made. There is sufficient equipment and adaptations within the home. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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): 27,28,29,30 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. The numbers and skill mix of staff meets service users needs. Staff are working towards ensuring service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are working towards ensuring they are fully trained and competent to do their jobs. EVIDENCE: The duty rotas were observed and demonstrated that sufficient staff are employed to meet service users needs. Staff and service users spoken with substantiated this. Four members of staff have attained the national vocational qualification (NVQ) level 3, two members of staff have commenced level two and two are due to start level 2. The domestic staff have completed a NVQ relevant to their job role and responsibilities. A new induction programme has been introduced and covers the requirements; there was evidence within staff files of this taking place. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 Page 18 Four staff files were observed and contained the required documentation, the manager discussed the recruitment process and how she is looking towards developing this further. Staff development plans have now been introduced and the quality assurance system demonstrated that an analysis has taken place. All training needs have been prioritorized, some training has taken place and additional mandatory training has been arranged. Staff spoken with stated they felt supported and their training needs were met. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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): 31,33,35,38 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. 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 fully. The home is run in the best interests of service users. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager is a registered nurse and has attained a postgraduate management degree and the national vocational qualification managers award. She has been the manager of the home since 1997 and therefore has the required knowledge and skills. She continues to remain up to date in her Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 Page 20 practice via study days and training courses. Staff spoken with stated that they felt supported and valued 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. The manager has commenced the implementation of the new quality assurance documentation and there was evidence within this to demonstrate that this is now being worked towards. The manager stated this has taken time however it is intended that it will be completed in the near future. At present time is being spent on a staff training analysis and a development plan for the home. Although no questionnaires have been sent to service users or relevant others the manager stated that she ensures she remains available at all times for informal discussions and care plan reviews are held four monthly. 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 records and certificates were available for inspection. Water temperatures are recorded monthly. The manager stated that a risk assessment with regards to legionellosis is in the process of being completed. There was evidence within the fire log book to demonstrate that relevant testing was taking place, staff spoken with substantiated that they had undertaken fire drills and training. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 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 3 Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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 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. Timescale for action 22/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP30 OP33 Good Practice Recommendations Continue to work towards ensuring all staff complete mandatory training to evidence that staff are fully trained and competent to do their jobs. Continue to implement the quality assurance systems in all areas of the home to evidence that a quality service is being delivered in the best interests of service users. Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Woodthorpe Manor Care Home DS0000026482.V307194.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!