Inspection on 27/02/06 for Woodville Rest Home

This inspection was carried out on 27th February 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

Woodville Rest Home 09/06/08

Woodville Rest Home 12/06/07

Woodville Rest Home 19/06/06

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 Mike Flint Announced Inspection 27th February 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.V273447.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 DS0000062808.V273447.R01.S.doc Version 5.0 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) 0208 949 4507 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.V273447.R01.S.doc Version 5.0 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 25 August 2005 Date of last inspection Brief Description of the Service: Woodville is a detached property set in a quiet residential area of Bexhill-onSea, close to Egerton Park, the seafront and the town centre. Residents’ accommodation is provided on two floors. The home has a stair lift. Woodville provides residential and social care for seventeen older people with dementiatype illnesses.There are currently three rooms registered for double occupancy. Sufficient toilets and bathrooms/ showerooms are provided. Seven of the service user’s rooms have en suite facilities.To the rear of the property there is a small, well-kept private garden and a spacious, detached sun lounge for residents use. Woodville DS0000062808.V273447.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out over 5 hours during a day in late February, when there were fifteen residents. The temporary acting manager assisted throughout the inspection, in the absence of the registered manager due to her maternity leave. The Inspector was able to have a general conversation with some of the residents, when joining them for lunch, and subsequently spoke with three residents in the privacy of their own rooms. Each of the duty staff were interviewed individually during the course of the inspection. Prior to the inspection, eight comment cards had been completed by relatives and forwarded to the Inspector; one relative and a social worker were contacted by ‘phone; comments were also received from a District Nurse, who has current, first hand knowledge of this residential home from regular visits. There was contact with the homeowner also. The Inspector thanks all those who have contributed to this inspection with their comments and to the acting manager, staff and residents for their willing participation on the day of the visit. What the service does well: What has improved since the last inspection? A continuing emphasis on training has ensured that there is an on-going availability for all staff to undertake NVQ training and training in safe working practices with additional courses being accessed also e.g. dementia care, continence, bereavement and health and safety. Following a recent visit from the Environmental Health Department, a revised method of recording issues relating to food safety is to be introduced. The fulltime cook and other staff who are involved in the preparation of meals now hold current food hygiene certificates. Staff contracts of employment are in process of being re-issued by the new homeowner. The homeowner is present in the home on a weekly basis to provide management support and undertake maintenance tasks. Woodville DS0000062808.V273447.R01.S.doc Version 5.0 Page 6 The registered manager has produced a suitable format for the required monthly self-audit checks on the home’s performance, though the procedure for its implementation needs to be revised in accordance with the guidance, given in Regulation 26 of the Care Standards Act. 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.V273447.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 DS0000062808.V273447.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, 4, 5 The home has suitable procedures in place to ensure that the needs of those admitted can be met. EVIDENCE: Detailed pre-admission assessments are carried out and recorded; examples of these were seen to be well-presented in residents’ care planning documents, for the advice of care staff. Two, recently admitted residents confirmed that they had visited the home, prior to their admission, and made a positive choice in agreeing to a trial period of residency. A relative spoken with said the home ‘had done wonders’ in meeting the challenging needs of a resident. Visiting professionals also spoke highly of the staff’s ability in providing a high standard of care, in circumstances that could sometimes be very demanding of their skills. Many of the comments received from visiting relatives made reference to the ‘relaxed and homely’ atmosphere, always to be found in the home. An emphasis on training ensures that care staff are competent in carrying out their responsibilities. Woodville DS0000062808.V273447.R01.S.doc Version 5.0 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, 11 The staff have a good understanding of the residents’ support needs and this is evident from the positive relationships, which have been formed between staff and residents. EVIDENCE: Four of the residents’ care-plan files were inspected; in each the documentation was well presented, consistently recorded and up to date. The information given was readily accessible for staff; the acting manager said that it was the key workers’ responsibility to ensure the daily records and individual monthly review notes were completed; this was found to be the case. Each care plan includes details to be followed in the event of a resident’s death. From speaking with the acting manager and visiting professionals it was clear that positive links are maintained with the Community Healthcare Services. A senior staff, with overall responsibility for medicines within the home, showed the Inspector the records kept and described the procedures, adopted by the home in the satisfactory administration of medications. No resident has responsibility for their own medicines, unless they have been assessed as competent in this area of self-care. In talking with a relative the Inspector was told how impressed they had been by the patience shown towards a resident and the degree of sensitivity that Woodville DS0000062808.V273447.R01.S.doc Version 5.0 Page 10 was apparent in the staff group as a whole, in meeting residents’ right to privacy and respect. Further examples of this were observed during the course of the inspection and the home is to be commended on the high quality of care, provided to each resident; another factor that visiting relatives made comment on. Woodville DS0000062808.V273447.R01.S.doc Version 5.0 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 The home provides a relaxed and supportive environment that is beneficial to the residents’ wellbeing. Family visits are encouraged for the enjoyment of residents and in support of their emotional needs. EVIDENCE: Residents are encouraged to make choices, wherever possible in their daily lives e.g. how to spend their time, what clothes to wear, daily routines and mealtime choices. The Inspector was told that activities take place in the home on most afternoons, or whenever duty staff are available to engage residents in these e.g. bingo, jigsaws, manicure and hairdressing. A resident said that when she felt better it would be nice to be involved in setting the table up for meal times; another resident has assisted in simple kitchen tasks, under the supervision of the cook; a third said she would like to receive communion sometimes. Many of the residents enjoy being taken out for walks, when the weather allows this. In order to ensure that all residents’ needs are being met in this respect, it is recommended that a volunteer staff member be asked to take responsibility of consolidating activities, undertaking some appropriate training for this purpose i.e. through Age Concern, Alzheimer Society among others. When questioned by the Inspector, staff had no information about a resident’s past life history, before entering the home three months previously, and there Woodville DS0000062808.V273447.R01.S.doc Version 5.0 Page 12 were no relevant details recorded. The Inspector suggests that key workers, with the help of residents and/ or their relatives, compile brief life histories for each resident, so that their personal interests may be better known and thereby more effectively addressed. One resident commented that she enjoyed reminiscing about her life. The home benefits from daily visiting by relatives and there is an atmosphere of welcome from the staff in the home; several relatives had commented how this made their visits more enjoyable. A varied and nutritious diet is provided; the meals served being of good quality and the cook changes the menu every few months, according to the season. Residents spoken with said that they enjoyed their meals. The meal served on the day of the inspection was hot, tasty and nicely presented. Woodville DS0000062808.V273447.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, 18 Any matters of concern are handled appropriately, reassuring those involved that they are being listened to and that action will be taken, as necessary. EVIDENCE: The home has a satisfactory complaints procedure in place and there is a suggestions box in the reception office; residents and relatives particularly commented on how approachable they found the manager and staff. So that all staff would be clear about what to do in case of suspected abuse, the Inspector advised that the procedure to be followed should be included together with the policy on the protection of vulnerable adults. Staff have received training in this area of their work and records are kept of this. Woodville DS0000062808.V273447.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): 19, 20, 21, 22, 23, 24, 25 The home provides a pleasant environment that meets residents’ individual and collective needs in a comfortable, homely style. However, further work is required if the home is to reach satisfactory standards of maintenance and access to all communal areas. EVIDENCE: The layout and location of the home is suited for its purpose, providing a safe and homely environment. A private rear garden is maintained for residents’ use in the warmer weather. Access to the spacious garden sun lounge is somewhat restricted, dependent on weather also; there is a requirement that this area should be made available at all times, as it represents a large potion of the residents’ shared space. The home-owner has consulted with an architect in pursuing this requirement. Within the home, the small communal lounge is comfortably furnished in a domestic style. The adjoining dining area requires upgrading with suitable, replacement furnishings, where these are heavily worn and potentially hazardous. Woodville DS0000062808.V273447.R01.S.doc Version 5.0 Page 15 There are sufficient toilets, bathrooms and a shower room. At the time of the last inspection it was noted that the bath hoist was unusable and that the chair, provided in the shower room was not fit for the intended purpose; both items remain outstanding, though the Inspector was informed that the owner has these matters in hand to deal with. Handrails and grab handles have been fitted and wheelchairs provided, where these are needed for residents’ safety. Most residents’ private rooms are furnished and decorated to a satisfactory standard; however, there is a need for an on-going programme of improvements and redecoration of those rooms, where this is needed. The overall standard of cleanliness in the home appeared to be good, though odours were apparent in one of the resident’s private rooms and a relative had commented on the issue. The home employs a full-time cleaner, who was able to confirm that carpet cleaning equipment was provided and regularly used as a measure to minimise the presence of any unpleasant odours. Woodville DS0000062808.V273447.R01.S.doc Version 5.0 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 Staff continue to co-ordinate their efforts and work together as an effective team, providing a commendably high quality of care. EVIDENCE: At the time of the inspection staffing levels were appropriate in meeting residents’ needs. The duty rota shows either the temporary acting manager, or acting deputy together with three carers are rostered throughout the week. A full time cook and cleaner are employed. There are two waking night staff. Five staff have already completed NVQ training at levels 2 and 3 in Care. There are three others, currently working towards NVQ awards. The Inspector spoke with a recently appointed carer and was informed of a satisfactory recruitment process, including the taking up of references and a Police checks, prior to the commencement of their employment. The TOPSS induction and foundation training has been introduced for new staff. A record of training completed is retained in individual staff files. The Inspector suggested that a ‘training needs analysis’ wall-chart be produced to provide an at-a-glance record of training undertaken and that planned for, showing staff names, dates and course titles i.e. in a simple grid format. In this way ensuring that the required training and training updates are noted and acted on in a timely fashion. Woodville DS0000062808.V273447.R01.S.doc Version 5.0 Page 17 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, 38 Whilst the registered manager is on maternity leave, senior staff are acting up and competently maintaining a satisfactory level of continuity in the day-today management of the home. EVIDENCE: From observations during this visit and from the many positive comments received, the Inspector is of the view that the home continues to be run in the best interests of the residents. Woodville Rest Home clearly has achieved a deservedly good reputation. Although some of the staff training in safe working practices remains outstanding, the home’s health and safety procedures are satisfactory. The Inspector suggested that the senior staff member with responsibility for health and safety matters in the home undertakes specific training for this purpose. Woodville DS0000062808.V273447.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 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 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 1 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X X X X 3 Woodville DS0000062808.V273447.R01.S.doc Version 5.0 Page 19 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. 01 Standard OP20 Regulation 23(2) Requirement Timescale for action 01/09/06 02 OP20 16(2)(C) 03 OP22 16(2)(C) That the choice of communal areas is accessible to residents at all times i.e. that steps are taken to provide safe and sheltered access to the communal garden sun lounge. That furnishings in communal 01/09/06 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 serviceable equipment 01/04/06 suitable to the needs of residents is provided i.e. bath hoist and shower seat. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 01 Refer to Standard OP12 Good Practice Recommendations That steps are taken to ensure residents’ wishes for religious observances are identified and acted upon, as far as reasonably practicable e.g. regular communion should DS0000062808.V273447.R01.S.doc Version 5.0 Page 20 Woodville 02 03 04 05 OP12 OP19 OP26 OP33 this be requested. That a member of staff be identified to undertake training as an activities organiser for the residents at the home. That a programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept. That whatever steps are necessary be taken to ensure the premises are kept free from offensive odours. That an up to date edition of the National Minimum Standards, with Care Homes Regulations be provided for the advice and guidance of those with a management responsibility at Woodville Rest Home. Woodville DS0000062808.V273447.R01.S.doc Version 5.0 Page 21 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.V273447.R01.S.doc Version 5.0 Page 22 - 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. 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