Inspection on 16/06/05 for Woodville Care Home

This inspection was carried out on 16th June 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 01/11/05

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 DE11 7JW Lead Inspector Jo Wright Unannounced 16 June 2005 9.00am 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 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 C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodville Care Home Address 145 Burton Road Woodville Swadlincote Derbyshire DE11 7JW 01283 551501 01283 551413 Telephone number Fax number Email 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 PC Care Home only 34 Category(ies) of OP Old Age - 33 places registration, with number PD Physical Disability - 1 place of places Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one PD either sex. This person is named in the notice of proposal and the place will cease on the termination of this persons care at the home. Date of last inspection 20th October 2004 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. Service users bedrooms are located on the ground and first floor. Service users 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 C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection carried out over 7 and a half hours. Care files, medication, staffing and staff files were inspected. A small number of service rooms and communal areas were viewed. 4 service users, 1 relative, 4 members of staff as well as the Registered Manager were spoken with during this inspection. Due to ongoing non compliance with previous requirements, two immediate requirement notices were issued during this inspection (See Requirement Number 14 and 17). What the service does well: What has improved since the last inspection? Staff commitment to training has improved since the last inspection. Three quarters of the care staff team have completed the required training, as well as working through training booklets on a variety of other subjects relating to the care of people. A number of staff members have expressed an interest in continuing their studies in care. Night staffing cover has improved, which means that the minimum care staff hours are now provided. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 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 C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 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 standard(s) 3 and 4 Inconsistent use of the admission procedure did not ensure that a proper assessment of people was completed and documented, and therefore there was no assurance that care needs could be met. EVIDENCE: Individual records were maintained for each service user and records of two recent admissions were examined. Service user files were maintained on computer, although paper copies were also available. The Registered Manager indicated that both service users had been assessed prior to admission, although the files examined did not support this. Written confirmation that the needs could be met was not in place. The needs of one of the service users had not been fully assessed and recorded. Those service users and relatives spoken with confirmed that the staff at Woodville were able to meet their needs. Comments included that ‘this home is lovely’, ‘have been happy living here’ and ‘although relative was cared for in bed, no sores had developed’. Discussion with the Registered Manager and staff confirmed that alternative accommodation was found for service users whose needs could not longer be met at Woodville. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7, 8, 9 and 10 Delivery of care may be compromised due to inconsistency of record keeping. Some processes were not complete or used effectively to ensure that the health, social and safety needs of service users were fully met. The inconsistent use of some systems could potentially put service users at risk. EVIDENCE: The computer generated care plans examined contained details of best practice but did not make specific reference to the needs of individual service users. Discussion with staff demonstrated that they were aware of service users needs, but this information had been gathered through caring for the person and not directed by the plans of care. This approach relies on staff memory and good verbal communication systems. Infrequent review of assessment of need and care plans was taking place, but the records did not clearly identify any changes. Where asked, people did not know about their care plans. Daily logs were well maintained, although staff were not always following through entries, for example, recording how a person felt today if they had felt sick yesterday. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 10 Health care needs were being met at a basic level, through access to a range of health care professionals. However, inconsistent use of risk assessments did not promote service users health and welfare needs, as risks were not identified and appropriate action taken. The practice of using medication prescribed to named individuals for communal use was observed. The prescribing instructions for one service user’s medication had not been followed, resulting in the medication not being administered. Systems in place did not assist staff to administer medication to the correct person, as photographs were not available with all medication sheets. One medication record sheet had not been altered appropriately to reflect the change in dosage as recorded in the file. Staff responsible for administration of medication confirmed that they had received training, and this was evidenced in the training records. They confirmed that the Registered Manager had observed their practice to check their competence, but this information had not been recorded. Service users spoken with felt that their privacy and dignity was respected. Service users spoke very highly of the staff team, and the care and attention that staff provided. Service users confirmed that they had been provided with a key to their room and locked the door as they wished. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12 and 13 Social activities were well managed and provided variation and interest for people. Staff supported service users to maintain links with their family, friends and local community. EVIDENCE: Service users spoken with were aware of the activities that were organised on a regular basis. One service user reported how they enjoyed the activities, whilst another commented that they did not want to join in or socialise with other people and staff respected this. People spoken with commented that they enjoyed their visits to the hairdresser when she was in, and visits by members of the local church. Service users and visitors confirmed that they were able to visit at any time, and visitors were always made to feel welcome on arrival. Visits by family and friends were recorded in individual files. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18 Staff were unaware of the external organisations involved in the protection of vulnerable adults, which potentially put service users at risk of not being protected from abuse. EVIDENCE: Staff spoken with confirmed that they had received training on how to recognise abuse as part of their NVQ training and had some knowledge of what action to take within the home. However they were unaware of the local authority procedure, did not know who to report to outside of the home, or where they could contact social services or the Commission for Social Care Inspection, which potentially puts service users at risk. Staff had not attended training provided by the local authority on the Protection of Vulnerable Adults. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 23 and 24 The environment was comfortable, and maintained to a good standard. A safe environment was not being maintained due to several service certificates being out of date. Bedrooms reflected individual preferences and contained personal belongings. EVIDENCE: Woodville Care Home was well maintained and decorated, and ongoing investment in the building was noted. The communal areas provided were comfortably furnished. The furniture provided in bedrooms was according to the service users own choice, and the rooms seen during this inspection contained personal belongings. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The deployment and numbers of staff appeared satisfactory to meet the needs of the current service user group. Staff received appropriate training to assist them to do their jobs. The procedures for the recruitment of staff were not robust and do not provide the safeguards to offer protection to people living in the home. EVIDENCE: Service users and relatives spoke highly of the staff team, and that all staff were kind and caring. Service users indicated that staff responded to their requests for assistance promptly. Care staff hours provided were satisfactory, with the Registered Manager working in a supernumerary capacity. Catering, domestic and laundry hours were sufficient to meet the needs of the home. Three quarters of the care staff had completed the required training towards NVQ Level 2. However, the systems in place for the recruitment of staff were not sufficiently robust. No progress had been made towards meeting the requirements in the previous inspection reports relating to the recruitment of staff and staff files. Criminal Record Bureau (CRB) checks on all existing staff have not been obtained. New staff were employed with CRB checks obtained elsewhere, not for this employment. The systems for recording when CRB checks had been obtained was poor, and relied on staff bringing in their copy of the CRB rather than the Registered Manager keeping the confirmation letter from the umbrella organisation which carries out the checks on behalf of the employer. The two staff files examined during this inspection were incomplete. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 15 Two systems were in place for induction training. Some staff worked through the induction booklet whilst other staff attended an induction course that met the specifications. Two other members of staff were attending the study day on the day of the inspection, and another was due to attend in the near future. Individual training files were maintained, with copies of certificates, although these records were not up to date. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 36, 37, 38 Inconsistent use of management systems relating to documentation may place service users at risk. Out of date service certificates for equipment did not safeguard the health, safety and welfare of the people using the service. EVIDENCE: The Registered Manager has been in post for a number of years, and was in the process of completing the Registered Manager’s award. No progress has been made towards providing evidence that Regulation 26 visits were being carried out by the owners, although the Registered Manager confirmed that these were taking place. Service users commented that the owners did visit the home regularly and speak with them. Service users and staff spoke highly of the staff team. Staff confirmed that felt supported by the Registered Manager, and were encouraged and supported to develop their skills and knowledge. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 17 Although systems were in place for staff supervision, it was clear from the records examined and discussion with staff that not all staff had received supervision and that supervision sessions occurred infrequently. Staff confirmed that they received the required training, and the individual training records generally supported this. However, as previously stated, training records were not fully up to date. The gas safety certificate and the lift examination certificate were out of date. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 3 x x 3 3 x x STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 2 3 x 3 x 2 2 2 Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 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 3 Regulation 14(1) Requirement Accomodation must not be provided to service users unless their needs have been assessed prior to admission. The assessment of service users needs must provide sufficient detail to enable staff to meet the service users needs. The assessment must be kept under review and having regard to any change of circumstance be revised as necessary. The Registered Person must confirm in writing to the service user that having regard to the pre-admission assessment the care home is suitable for the purpose of meeting the service users needs in respect of their health and welfare. (Previous timescale of 28/02/05 not met) All service users 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 Care plans must be kept under review (recommendation monthly) in consultation with the service user and/or Timescale for action 30 September 2005 30 September 2005 2. 3 14(1) & (2) 3. 4 14(1)(d) 31 July 2005 4. 7 15(1) 30 September 2005 5. 7 15(2) 31 July 2005 Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 20 6. 7 15(1) 7. 8 12(1)(a) & (b), 13(4)(c), 14(1)(a) 8. 9 13 & 17 Schedule 3 13(2) 9. 9 10. 11. 12. 9 9 9 13(2) 13(2) 18(1)(a) & (c) 13(6) & 18(1)(a) & (c) 13. 18 representative and detail why the care plan remains the same or has changed. (Previous timescale of 28 February 2005 not met) The Registered Person must demonstrate that care plans are drawn up with the involvement of the service user, recorded in a style that is accessible to the service user, and agreed and signed by the service user whenever capable, and/or representative (if any). The Registered Person must ensure that the relevant general (manual handling, falls, pressure area care and nutrition) and individual risk assessments are undertaken for all service users and the information recorded in individual plans Medication must only be administered to the service user for whom it is prescribed and labelled. Any change in dosage of medication should be clearly stated on the medication record, with details of who authourised the change and the date of commencement. Medication must be given to service users as prescribed. A system must be in place to identify the service user with the medication record. Records must demonstrate that staff who administer medication have received an assessment of competence The Registered Person must ensure that all staff members receive training provided by the local authority on the Protection of Vulnerable Adults (Previous timescale of 31 March 2005 not met) 30 September 2005 30 September 2005 31 July 2005 31 July 2005 31 July 2005 31 July 2005 31 August 2005 30 September 2005 Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 21 14. 29 19(1) & (4) 15. 29 17(2) Schedule 2&4 16. 29 19 Schedule 2 17. 31 26 18. 19. 36 37 18(2) 17 20. 38 13(4) Criminal Record Bureau (CRB) checks will be sent for processing for all staff employed by Greenacres Nursing Home Limited without a CRB which has been obtained on behalf of Greenacres Nursing Home Limited. This includes all existing staff without CRB checks and newly appointed staff. (Previous timescale of 28 February 2005 not met) Immediate requirement notice left The Registered Person must ensure that all staff files contain the required information in accordance with Schedules 2 and 4 (Previous timescale of 28 February 2005 not met) The Registered Person must update the staff application form in order to request an applicants full employment history, and written explanation of any gaps in employment. Regulation 26 visit reports to be available in the home at all times. Copies of these reports to be sent to the local area office of the Commission for Social Care Inspection. (Previous timescale of 31 January 2005 not met) Immediate requirement notice left All staff must be appropriately supervised and records available to support this. The Registered Person must ensure that all required records are maintained (Previous timescale of 28 February 2005 not met) The Registered Person must provide copies of an up to date gas safety certificate and lift examination certificate to the local area office. 16 July 2005 30 September 2005 31 July 2005 30 June 2005 31 August 2005 30 September 2005 31 July 2005 Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 22 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 30 Good Practice Recommendations Training records should be kept up to date. Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection South Point 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. Extracts may not be used or reproduced without the express permission of CSCI Woodville Care Home C52-C02 S20214 Woodville V231231 160605 Stage 4.doc Version 1.30 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. 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