Inspection on 19/06/06 for Woodville Rest Home

This inspection was carried out on 19th June 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 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 Rest Home 09/06/08

Woodville Rest Home 12/06/07

Woodville Rest Home 27/02/06

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

CARE HOMES FOR OLDER PEOPLE Woodville 8-10 Woodville Road Bexhill-on-sea East Sussex TN39 3EU Lead Inspector Angela Gunning Key Unannounced Inspection 19th June 2006 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 DS0000062808.V289745.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. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodville Address 8-10 Woodville Road Bexhill-on-sea East Sussex TN39 3EU 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) 01424 730497 01424 736479 Pages Homes Ltd Nina Cooper Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the number of registered places may not exceed seventeen (17). That the service users being admitted will have a dementia-type illness. That persons admitted be sixty-five (65) years, or older at the time of admission 27th February 2006 Date of last inspection Brief Description of the Service: Woodville provides residential and social care for seventeen older people with a dementia-type illness. The home is a detached property, set in a quiet residential area of Bexhill-on-Sea, close to Egerton Park, the seafront and the town centre. Residents’ accommodation is provided on two floors and there is a stair lift to access the first floor. There are 11 single bedrooms and three bedrooms registered for double occupancy. Seven of the service user’s rooms have en suite facilities. Sufficient toilets and bathrooms/ shower rooms with assisted facilitates are provided. The home provides lounge with a dining area and a spacious, detached sun lounge at the rear of the property. There is a small rear garden. The current scale of charges range from £352 to £450 and there are extra charges for hairdressing, chiropody and toiletries. Prospective residents can obtain information about the home via Care Finder who advertises the homes’ services and facilities on the internet and by requesting a copy of the homes’ Statement of Purpose and Service User guide. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which included a visit to the home for 5.5 hours, seeking information and the views of residents and relatives by survey and telephone contact. Information was gathered from the pre-inspection information provided by the manager and previous inspection reports. 8 surveys from relatives were returned to assist with the inspection process and 5 were returned from residents, who had been assisted by staff to fill these in. A district nurse was also part of the survey. One relative was contacted by telephone as part of case tracking resident’s admission and care. Several people were spoken to during the visit, including seven residents, two members of care staff, the deputy manager and the provider. Most of the environment was inspected, including the bedrooms, the communal areas, laundry room, sunroom and office. Two care plans, three staff file and medication records were examined. What the service does well: What has improved since the last inspection? At the previous inspection it was required that suitable arrangements are put in place for residents to access the sunroom. Prior to the site visit the provider had made a ramp leading from the dining room into the sunroom and during the site visit he was improving this facility. There is a new shower seat for the shower room on the ground floor and a new battery is in place for the bath seat in the bathroom on the first floor. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 6 Each resident’s religious denomination is recorded in their care plan and it was noted that residents are supported to participate in their beliefs. A new vacuum cleaner with washing facilities has been purchased to ensure that the premises are kept free from offensive odours. 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 DS0000062808.V289745.R01.S.doc Version 5.2 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 DS0000062808.V289745.R01.S.doc Version 5.2 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, (6 N/A) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There is a satisfactory preadmission assessment procedure in place to ensure the home can meet each person’s needs. EVIDENCE: Satisfactory preadmission assessments had been carried out on the two most recently admitted residents prior to them moving into the home to ensure that their health and welfare needs could be appropriately met. Telephone contact was made with a relative of one of these residents, who confirmed that her husband “had been offered a fortnightly trial period” and the family had been given sufficient information about the homes’ facilities and services, so that they could reach a decision about whether long-term care was right for her husband and she considers that her husband is “very happy there”. The home operates a keyworker system and one member of staff had supported this new resident’s move into the home go smoothly. The home does not provide intermediate care. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ healthcare needs are met by competent and caring staff who respect their privacy and dignity. EVIDENCE: The care plans of the two newest residents’ were examined and the deputy manager explained that these were being compiled. Although some detail in the recording of information was missing, it was noted that daily records are kept and care plans are reviewed by keyworkers on a monthly basis to ensure care needs are monitored and staff have the information needed to meet these needs. Feedback from relatives’ surveys indicates that ‘they are satisfied with the overall care provided’ and residents feel ‘they always receive the care and support needed’. It was noted that health and social care professionals, such as General Practitioners, District Nurses, Community Psychiatric Nurses and Social Workers are consulted when and as necessary and a record is maintained of these contacts and any agreed action necessary. One resident commented that ‘staff always help me when I have bad legs’. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 10 Staff had an understanding of the needs of people with dementia and were noted to be patient, kind and respected the individuality of each person. One relative spoken with over the telephone said, “it is so nice there, all the staff are very kind”. A visiting nurse contacted as part of the inspection considers that Woodville delivers a high standard of care.’ A senior member of staff has overall responsibility for ensuring the safe and efficient management of medication within the home. The procedures for the ordering, administration and recording of medication were noted to be well managed to ensure that residents’ medication needs are met. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents have choice and control in their everyday living at the home and the arrangements for leisure and social activities inside and outside the home provide opportunity for mental and physical stimulation. Meals are varied and nutritious to ensure residents dietary needs are met. EVIDENCE: Pre-inspection information provided by the acting manager indicates that residents are offered a range of social and leisure activities, such as board games, arts and crafts, garden games and walks to the park and into town. Surveys returned from residents indicate that ‘there are always activities arranged.’ Care plans contain information about each resident’s occupational and recreational activities in the past, to assist staff in meeting residents’ social and leisure needs. During the site visit staff were noted to interact with residents in a friendly and supportive manner. One member of staff was looking at a resident’s photo album with her and another resident was supported in completing a puzzle. In the afternoon one resident had a trip out to the park and a relative spoken with over the telephone said that her husband “used to like walking to the local park and staff take him out Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 12 sometimes to the park”. The previous inspection highlighted a need for an activities coordinator to be appointed and the acting manager said “she would take on this role when the registered manager returns from maternity leave”. Each resident’s religious denomination is recorded in their care plan. It was noted that residents are supported to participate in their beliefs as one resident receives Holy Communion at the home and residents can attend a nearby church. Relatives can visit the home at anytime and in private should they wish to do so. One relative commented on the homes’ ‘friendly and homely atmosphere’. The menus indicate that residents are provided with a varied and nutritious diet. The majority of surveys returned from residents indicate that residents ‘always like the meals at the home’ and residents spoken with during the site visit said they “liked the lunchtime meal”. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There is a satisfactory complaints procedure in place to ensure residents and relatives feel that any concerns or complaints will be dealt with appropriately. There are good arrangements in place to prevent and protect residents from the risk of abuse. EVIDENCE: There is a complaints procedure in place and feedback from surveys indicates that relatives and residents know how to make a complaint and have not had to. The pre-inspection information provided by the manager confirms that there have been no complaints made to the home or the CSCI. The home have an adult protection and prevention of abuse policy and procedures for staff to follow in the event of suspected abuse. The preinspection information provided by the acting manager confirms that in the last 12 months some staff have received training in adult protection and prevention of abuse. Recruitment records indicated that POVA first Criminal Records Bureau checks are carried out prior to any carer working at the home. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 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): 19, 20, 22, 26 Quality in this outcome is adequate. This judgement has been made using available evidence, including a visit to this service. Not all communal areas provide a safe, accessible or well-maintained environment for residents. EVIDENCE: Surveys received from residents confirmed that they consider the home is ‘always fresh and clean.’ The acting manager said that a new vacuum cleaner with washing facilities has been ordered to ensure the premises are free from offensive odours. During the site visit the home was generally clean, although it was noted that some bedrooms were quite dusty. The acting manager said that “a new cleaner is going to be employed as the present cleaner is moving over to care work”. It was also noted that some parts of the home were in need of redecoration and refurbishment, such as a concertina toilet door in one bedroom was broken, compromising this residents privacy and dignity; communal walls in the hallways and lounge were in need of decoration and old furniture and Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 15 equipment was being stored inside and outside of the sunroom, making the premises look unkempt. At the previous inspection it was required that furnishings in communal areas, such as the dining room furniture are replaced so that they are safe and ascetically pleasing. No action had been taken to address this issue. The provider has been asked to forward an annual redecoration and refurbishment plan to the CSCI. At the previous inspection it was required that suitable arrangements are put in place for residents to access the sunroom. Prior to the site visit the provider had made a ramp leading from the dining room into the sunroom and during the site visit he was improving this facility. During the site visit it was noted that there were unsatisfactory arrangements in place for the fire doors leading out into the garden and sunroom. This situation was discussed with a senior member of staff who has overall responsibility for fire safety procedures and the provider has been asked to consult a fire office about the arrangements. It was also noted that some plastic chairs were blocking the fire escape path into the garden. Staff spoken to said that there were insufficient wheelchairs in the home to assist residents move around inside and outside the home. During the site visit in was noted that two members of staff had to mobilise a resident to the toilet, as there was no wheelchair available to assist her. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 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): 27, 28, 29, 30 Quality in this outcome is adequate. This judgement has been made using available evidence, including a visit to this service. Staff are caring and competent in providing good care to older people. However, at times staffing arrangements do not ensure that residents’ health and welfare needs are met. EVIDENCE: Feedback from surveys indicates that relatives consider there are enough staff on duty throughout the day and night and through surveys residents feel there are ‘always staff available when you need them’. Pre-inspection information received from the acting manager indicates there has been a reduction of staff on duty since the manager went on maternity leave. The rota in January 2006 indicted that there were four members of staff in the home in the morning and afternoon and now there are three in the morning and three in the afternoon. The deputy manager confirmed she has been temporarily promoted to acting manager until the registered manager comes back from maternity leave in September and she is “having to do two jobs, as she has to be on the floor and staffing arrangements have been a bit difficult at times, due to sickness and hoildays.” It is recommended that a laundry assistant is employed to carry out domestic tasks so care staff can spend more time with residents. During the site visit it was noted that staff were very supportive and attentive to each resident and relatives spoken with confirmed that “staff are very kind to residents”. There are currently fifteen residents living at Woodville and the rota showed that there are three carers in the morning, three in the afternoon, Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 17 which includes either the acting manager or acting deputy manager and two working a waking night shift. However, in the afternoon of the site visit it was noted that there were only two members of staff on duty, including the acting manager who was meant to be off shift. These two members of staff had to mobilise a resident to the toilet, as there was no wheelchair available to assist in this process. This meant there were no staff present in the lounge to monitor or assist with other residents. This unsatisfactory situation was discussed with the provider and it is acknowledged that unfortunately, one member of staff had to go home due to personal circumstances. The provider also explained that on the morning of the site visit a member of staff who was meant to be working in the afternoon had called in sick. However, alternative staffing arrangements had not been made, putting residents and staff at risk of harm. Pre-inspection information provided by the manager confirmed that staff receive a variety of training, such as moving and handling, infection control, first aid and challenging behaviour to ensure their care practice is kept up to date and they can meet residents’ needs. Staff spoken with confirmed that they “receive adequate training” and pre-inspection information confirms that the home have 40 of staff with National Vocational Qualification (NVQ) in Care. Recruitment records indicated that there is a satisfactory recruitment procedure in place and Protection Of Vulnerable Adults (POVA) first checks are carried out prior to any carer working at the home whilst awaiting their Criminal Records Bureau (CRB) check. Staff have a thorough induction training when they begin working at Woodville. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 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 Quality in this outcome is adequate. This judgement has been made using available evidence, including a visit to this service. The temporary management arrangements are satisfactory, although this has reduced care staffing levels, which at time are insufficient to meet the needs of residents. EVIDENCE: Whilst the registered manager is currently on maternity leave the senior staff are acting up. Management arrangements appear to be satisfactory, although this has had implications on care staffing levels and has meant less staff on the floor and the acting manager is “trying to do two jobs”. As part of the homes’ quality assurance procedures the provider carries out monthly monitoring visits and the home carries out surveys with residents and relatives. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 19 Pre-inspection information indicates that all health and safety checks are made and recorded. The home has recently had an electrical wiring check and the provider has been asked to forward a copy of the certificate to the CSCI when this has been issued. The provider has also been asked to consult with a fire officer about the arrangements for the dining room fire doors. Due to residents having a dementia type illness, they do not have control of their own money. The home keeps a record of any items purchased on their behalf and relatives/representatives are invoiced for these. Although there is also an annual general management plan in place and a maintenance list that is dealt with by the provider, some staff spoken with felt that the “maintenance of the home is not up to scratch” and were concerned that “the good reputation of the home would be lost”. As communal walls in the hallways and lounge were in need of decoration and old furniture and equipment was being stored inside and outside of the sunroom, making the premises look unkempt. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 15 2 2 X 2 X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 3 x 3 x x 2 Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 21 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. 2. Standard OP20 OP20 Regulation 23(2)(d) 16(2)(C) Requirement That an annual redecoration and refurbishment plan is sent to the CSCI. That furnishings in communal areas are domestic in character and of good quality, in particular that replacements be provided, where dining room furniture is heavily worn, or unsafe. That the concertina toilet door in room 12 is mended. That old furniture and equipment is appropriately stored or disposed so the home does not look unkempt. That the home has suitable number of wheelchairs for residents use. That the chairs blocking the fire escape route are removed. That staffing numbers reflect the needs of residents at all times. To forward a copy of the electrical wiring certificate to the CSCI. That the home is kept clean and as free from dust as possible. Consult with a fire officer about DS0000062808.V289745.R01.S.doc Timescale for action 31/07/06 01/09/06 3. 4. OP19 OP19 23(2)(b) 23(5) 19/06/06 19/06/06 5. 6. 7. 8. 9. 10. Woodville OP22 OP19 OP27 OP38 23(2)(n) 23(4) 18(1)(a) 23(4) 23(2)(d) 23(4) 31/07/06 19/06/06 19/06/06 31/07/06 19/06/06 19/06/06 Page 22 OP26 OP19 Version 5.2 the arrangements for the dining room fire doors. 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 OP26 Good Practice Recommendations That a laundry assistant is employed to carry out domestic tasks so care staff can spend more time with residents. Woodville DS0000062808.V289745.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 DS0000062808.V289745.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!