Inspection on 01/11/05 for Woodville Care Home

This inspection was carried out on 1st November 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodville Care Home 18/11/08

Woodville Care Home 24/07/06

Woodville Care Home 16/06/05

Woodville Care Home 20/10/04

Woodville Care Home 08/04/04

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 Woodville Care Home 145 Burton Road Woodville Swadlincote Derbyshire DE11 7JW Lead Inspector Jo Wright Unannounced Inspection 1st November 2005 11:00 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 Woodville Care Home DS0000020214.V263463.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. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodville Care Home Address 145 Burton Road Woodville Swadlincote Derbyshire DE11 7JW (01283) 551501 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) Greenacres Nursing Home Limited Wendy Davies Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (1) of places Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one PD either sex. (This person is named in the noticed of proposal (Mrs Elaine West) this agreed place will cease on the termination of this persons care at the home. 16th June 2005 Date of last inspection Brief Description of the Service: Woodville Care Home provides personal care for up 34 people, 33 people aged 65 years and over, and 1 place for a named person under the aged the 65 years. The property is a purpose built, two storey building. Residents bedrooms are located on the ground and first floor. Residents access the first floor by using the staircase or passenger shaft lift. All bedrooms are single occupancy, and 31 rooms have ensuite facilities. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection lasting 4.5 hours. A number of residents were spoken with during the inspection. Records such as care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual service users) were not examined in depth during this inspection. Other records such as servicing of equipment records, staff files, residents monies and medication records were examined. A number of residents and staff were spoken with. An assessment was made with respect to the requirements made at the last inspection of this service. The manager was present at the inspection, and the findings the inspection were discussed with her. What the service does well: What has improved since the last inspection? Efforts have been made to update residents’ assessments of needs and care plans, although further development and staff training was still required. Those files that contained detailed information provided staff with sufficient information about the needs and abilities of individual residents on which to base their care. However, consistency of care could not be guaranteed, as detailed care plans had not been written. Appropriate checks were carried out on new staff to make sure that only people suitable to work with vulnerable people were employed. Efforts to protect people living in the home from potential abuse had been made. Senior staff had attending training on the Protection of Vulnerable Adults procedures and abuse. All staff attending this training would further strengthen this protection. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The information recorded within some residents’ assessments was insufficient to ensure that individual needs were fully identified and planned for. The admission process did not fully support that a persons needs would be met at the home. EVIDENCE: Information about residents was stored on computer. A random sample of records was looked at. Staff had made efforts to record more detailed information about each persons abilities and the support and assistant that they required from staff. However, the quality of the information recorded depended on which member of staff completed the records. When completed in detail, the assessments provided staff with sufficient information to meet the individual residents needs. New residents were not admitted to the home unless a senior member of staff had assessed them. The completed paperwork did not always dated or record whether the home could meet the individuals needs. A previous requirement to confirm in writing that the home is suitable for the resident has not been Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 9 met. The manager reported that she has just started to introduce this for new admissions. Woodville Care Home DS0000020214.V263463.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, 8, 9 and 10 Information recorded in resident care files was quite detailed, but the way it is organised does not provide a comprehensive and effective system. Staff did not always have clear and specific written guidance to follow in order to meet residents’ care needs, and care could not be evaluated easily. This places residents at potential risk of not having their individual needs met. EVIDENCE: Residents spoken with commented that staff working in the home were kind and caring, and provided support and assistance as required. Residents said that they were happy living at the home, and ‘it couldn’t be better’. Staff were polite and courteous when speaking with residents, and attended to their requests for assistance as promptly as possible. The care plans remain unchanged since the last inspection, resulting in staff delivering care from memory and from information shared between shifts. This may result in the individual needs of each resident not being met. The computer system in use does not allow staff to write their own care plans. Information on meeting the needs of individual residents was recorded in the assessments that were detailed. This information needs to be written up as a Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 11 plan of care. This was discussed with the manager, and consideration needs to be given to hand writing the care plans until the computer system can be amended or changed. Staff should be supported to continue to develop their assessment and care planning skills, so that more detailed information is recorded in the assessments and care plans are developed from the assessment. Staff should also be supported and encouraged to involve residents in reviewing their assessments and care plans and recording this information in the daily logs. Staff were using the assessment tools more effectively and recording relevant information about potential risks. This enabled staff to take appropriate action to minimise the risk occurring, for example breakdown of skin. Again, staff need to develop this information into a plan of care. Staff need to improve their practice with regard to medicines. The administration of medication was poor, placing residents at risk of not having their health needs met. The medication records did not support that residents received their medication, including creams, as prescribed. Systems were not in place to ensure that short in use date medication was marked with the date first used, or discarded as appropriate. Consequently, staff had been using medication (eye drops) that was out of date. The dispensing label had been removed from a box of ‘fybogel’. There was no information recorded on medication records to indicate who had authorised changes in dosage and when this had occurred. One resident had not received their pain killers as prescribed (every 72 hours). This was identified as the controlled medication register indicated that the medication had not been given, even though the member of staff had signed the medication record. As a consequence, this resident was two days late receiving this medication. The same member of staff had written new medication on the medication record as ‘eyedrops 4 x day both eyes’ and had been signed as administered. This entry not been dated or signed. This member of staff’s practice is not acceptable. The manager reported that the requirement for records to demonstrate that staff were competent to administer medication was ongoing. The findings of this inspection show that not all staff that administer medication were competent to do so safely. The manager should prioritise these assessments and provide additional training and supervision as required. Woodville Care Home DS0000020214.V263463.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): 14 and 15 Residents were encouraged to exercise choice over their lives as far as possible, and the routines at the home reflected this. Residents were provided with meals that were varied and which they enjoyed. EVIDENCE: Residents were encouraged and supported by staff to remain as independent as possible. One resident talked about a recent trip to the local town with a member of staff to buy new clothes, whilst another was being supported to go swimming with their family. Residents were observed making choices about how to spend their day and whether they wished to join in with the activities. Although no one was currently using the advocacy services, the manager was aware of the contact details. All of the residents spoken with commented that the meals were very good, and that they were offered a choice and variety. New menus had been introduced and residents were happy with the choices on offer. The Environmental Health Officer did not raise any issues following their recent inspection of the kitchen. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents felt able to raise issues with the management and staff, and confident that their complaints would be listened to and acted upon. Ongoing staff training was required to ensure that residents were protected from potential abuse. EVIDENCE: Residents spoken with confirmed they would raise any issues with the manager and were confident that these would be dealt with. Information on how to make a complaint was included in the Welcome Pack and on display in the home. Neither the manager nor the Commission has received any complaints about the care and services provided at Woodville Care Home. The manager reported that she takes a proactive approach and deals with any minor issues as they arise. Not all staff have received training on the protection to vulnerable adults and abuse. This could result in residents not being fully protected from abuse. The senior member of staff on each shift has received training provided by the local authority on the Protection of Vulnerable Adults procedure. The manager reported the information from this training will be shared with all staff, and there are plans to book all staff on the local authority training in the future. No referrals have been made through the Protection of Vulnerable Adults procedures. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents were provided with a comfortable and homely environment to live in. EVIDENCE: Woodville Care Home was well maintained and decorated, providing a comfortable and homely environment for people to live in. The manager reported that the owners plan to replace the ground floor corridor and main lounge carpet, and the comfortable chairs in the lounge. A maintenance person has been employed for 16 hours a week. Equipment for testing portable electrical appliances had been bought, and the maintenance person will receive training on how to carry out these tests. The laundry area was well organised. All equipment was in good working order. Systems were in place for labelling personal clothing, and returning clothing to the correct rooms. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 15 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 Robust procedures for the recruitment of new staff were in place and provided the safeguards to offer protection to people living in the home. EVIDENCE: Systems have been introduced to ensure that all of the required information was obtained for newly appointed members of staff. However, the manager acknowledged that the staff files for existing staff were not fully up to date. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 16 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, 36, 37 and 38 Whilst the home was generally run in the best interests of the residents, there was a lack of formal quality assurance, quality monitoring and staff supervision to provide the basis for improving the service for the residents and ensuring that care was always of a high standard. There has been progress in training staff in safe working practices, to promote the safety of the residents. EVIDENCE: The manager has been in post for a number of years, and reported that she has completed the Registered Manager’s award. Although the owners visit the home regularly and speak with residents, relatives and staff, the reports from these visits were still not available in the home. Therefore the owners were unable to demonstrate the level of support that they provide to the residents and staff at the home. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 17 Residents were asked for their views and comments on a regular basis through residents meetings. Residents’ suggestions were listened and acted upon, for example recent changes to the menu and more home made choices. Regular care reviews for both local authority funded and privately funded residents take place, with written notes available in the files. This provides people with an opportunity to raise both positive and negative comments about the care and services provided at the home. The manager reported that a formal resident satisfaction survey had not been carried out during the previous three months. The findings of this inspection did not support that residents’ monies were fully safeguarded within the home. Although systems were in place, these were not always followed correctly. The records of money held in safekeeping and the actual amount differed for a number of residents. The staff team as a whole were still not being appropriately supervised. The consequences of this can be seen in the poor staff practice relating to medication, and the variation in detail in resident files depending on the member of staff. An organised and documented system needs to be introduced to ensure that appropriately supervised staff care for the residents. Discussion took place with the manager about using opportunities as they arose for supervision, and well as planned supervision sessions when the manager worked alongside a particular member of staff. Mandatory training was provided staff. However, only senior staff have attended first aid training. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 18 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 2 2 Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 19 Yes 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 OP3 Regulation 14(1) & (2) Requirement The assessment of residents needs must provide sufficient detail to enable staff to meet the their needs. The assessment must be kept under review and having regard to any change of circumstance be revised as necessary (Previous timescale of 30 September 2005 not met) Confirmation in writing must be given to the resident, that having regard to the preadmission assessment the care home is suitable for the purpose of meeting the residents needs in respect of their health and welfare (Previous timescale of 30/09/05 not met) All residents must have care plans that set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs are met (Previous timescale of 30/09/05 not met) Care plans must be kept under review and demonstrate the resident and/or representative DS0000020214.V263463.R01.S.doc Timescale for action 31/03/06 2 OP4 14(1)(d) 31/12/05 3 OP7 15(1) 31/03/06 4 OP7 15(2) 31/03/06 Woodville Care Home Version 5.0 Page 20 5 OP9 13(2) & 17(1)(a) 13(2) 13(2) 13(2) 6 7 8 OP9 OP9 OP9 9 OP9 13(2) 10 OP9 13 & 17(1)(a) Sch 3 18(1)(a) & (c) 11 OP9 12 OP18 13(6) 18(1)(a) & (c) 17(2) Sch 2&4 13 OP29 14 OP31 26 has been involved in this process (Previous timescale of 31/07/05 not met) All prescribed medication must be administered according to the Prescribers instructions and recorded accordingly. Robust systems must be in place to ensure that all medication in the home is within date Medication dispensing labels must not be removed from the original container. Any change in dosage of medication must be clearly stated on the medication record, with details of who authorised the change and the date of commencement (Previous timescale of 31/07/05 not met) The person completing hand written medication records must sign these, and the records must checked for accuracy and countered signed by another person. All hand written entries on the medication records must include the name, dose and administration instructions. Staff responsible for administration of medication must receive appropriate training and be assessed as competent to carry out this task. Records must support this. All staff members must receive training provided by the local authority on the Protection of Vulnerable Adults (Previous timescale of 30/09/05 not met) Staff files must contain all of the required information in accordance with Schedules 2 and 4 (Previous timescale of 30/09/05 not met) Regulation 26 visit reports must be provided to the manager and DS0000020214.V263463.R01.S.doc 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 31/12/05 31/03/06 31/03/06 30/11/05 Page 21 Woodville Care Home Version 5.0 15 OP33 24 16 17 OP35 OP36 17(1)(a) Sch 4 18(2) 18 19 OP37 OP38 17 18)(1)(a) & (c) the Commission for Social Care Inspection, and a copy of the report available in the home. Systems for reviewing, and where necessary improving, the quality of the service and publish the results of findings must be developed and implemented e.g. satisfaction surveys. Robust systems must be in place to safe guard residents monies. All staff must be apporpriately supervised and records available to support this. (Previous timescale of 31/08/05 not met) All required records must be maintained (Previous timescale of 30/09/05 not met) All staff must receive training in basic first aid. 31/03/06 31/12/05 31/03/06 31/12/05 31/03/06 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 Refer to Standard OP7 Good Practice Recommendations Staff should be supported to continue to develop their assessment and care planning skills. Woodville Care Home DS0000020214.V263463.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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