CARE HOMES FOR OLDER PEOPLE
Woodway House 11 Enderby Road Blaby Leicestershire LE8 4GD Lead Inspector
Helen Abel Unannounced Inspection 1st November 2005 9:30 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 Woodway House DS0000001842.V262689.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. Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Woodway House Address 11 Enderby Road Blaby Leicestershire LE8 4GD 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) 0116 2773890 0116 2773530 Mr Shabbir Hakimuddin Kaka Mrs Naseem Shabbir Kaka Mrs Ruth Shardlow Care Home 32 Category(ies) of Dementia (6), Mental disorder, excluding registration, with number learning disability or dementia (6), Old age, not of places falling within any other category (26) Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service User Numbers. No person to be admitted to the home in categories DE(E) or MD(E) when 6 persons in total of these categories/combined categories are already accommodated in the home. 20th June 2005 Date of last inspection Brief Description of the Service: The home is set back off Enderby Road in Blaby and offers care for 32 people. 26 beds are in the category of older people and 6 in mental disorders and dementia. The accommodation is set in a large spacious house on two levels. Service users rooms are mainly bright and airy. There are several lounges available and a spacious dining area. There is a paved area leading out from the side of the home with garden furniture available. The home is well located and lies close to the centre of Blaby where it is accessible to local shops and facilities. The home operates a no smoking policy. Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced during a week day morning for around four hours. Four residents, staff and the Registered Manager were interviewed. A full tour of the premises took place, with records, policies and procedures examined. What the service does well: What has improved since the last inspection? What they could do better:
Produce a risk assessment for maintaining safe working practices. Undertake repairs to a bathroom floor and consider alternative air fresheners. These aspects will further protect residents and staff. Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 6 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. Woodway House DS0000001842.V262689.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 Woodway House DS0000001842.V262689.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): 1,2,3,4,5 The assessment system for new residents is fully implemented. EVIDENCE: New residents receive an assessment of their need prior to coming into the home. This is undertaken by the Registered Manager. Family and friends maybe involved in this process, and this is reflected in the written assessment. New residents and their families are invited to visit the home and see the bedroom and spend some time at the home. Written information is given out about the home and was evident in resident’s rooms. Woodway House DS0000001842.V262689.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): 10,11 Residents are treated with respect and their right to privacy upheld. EVIDENCE: A resident told the Inspector “ I like to stay in my room. I have told the staff that’s what I want to do. They come and talk to me and help me down for meals.” Staff were observed positively interacting with residents talking and laughing together. The Registered Manager had arranged for the hairdresser to come in specifically to see one new resident have her hair done. Normally the hairdresser comes in fortnightly. Policies and procedures around death and dying are in order. The Registered Manager confirmed she had identified bereavement training and will be arranging this soon. Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 10 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): Outcomes 12-15 were inspected and found to be compliant at the last inspection. EVIDENCE: Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 11 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): 16,17 Residents can express their views. Any concerns are dealt with before the situation affects the resident’s well being or results in a complaint. EVIDENCE: The Registered Manager confirmed at the general elections residents chose to go out and vote and were escorted to the local polling stations. This confirms residents legal rights are protected. Two residents were observed raising concerns with the Registered Manager around heating in their room and arrangements to go to the Age Concern Drop In. Both issues were promptly dealt with. The Registered Manager confirmed she welcomed and encouraged residents to come and talk about anything with her, or the staff. Residents made the following comments: “I wouldn’t be anywhere else. Very happy here, meals are good. They will do anything for you” “ It’s fine. I know I can speak to Ruth (Registered Manager)” “I am well looked after.” “On Monday they wash my clothes, iron them and when I told the staff my hem had come down on my trousers they mended it straight away.” Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 12 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): 23,26 The home was clean pleasant and hygienic. EVIDENCE: Resident’s bedrooms were viewed and were found to be clean and comfortable, and individualised with resident’s furniture. One resident said, “They clean the bedrooms well, everything is kept clean and tidy.” Some building work is due to commence around the removal of a redundant staircase. The fire service and local authority are currently involved in this process. Residents and families and friends are being kept informed as well. The outdoor courtyard area was well presented with garden furniture and is frequently used by residents in the warmer weather. Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 13 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 Resident’s needs are met by the numbers and skill mix of staff. EVIDENCE: Residents made the following comments: “Staff are friendly” “I went out to the shops with one of the staff. If I need something I will ask the staff to get me things.” “Staff are good.” The Registered Manager confirmed staff are undertaking a range of training in dementia care, and National Vocational Qualifications (NVQ) in care. Over 50 of the staff holds an NVQ qualification. Staff have recently completed infection control, first aid, and accredited medication training. The home’s commitment to staff training is to be commended. Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 14 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): 32,34,35,36,37,38 The health, safety and welfare of residents are on the whole sufficiently promoted and protected. EVIDENCE: Through observation it was evident the Registered Manager communicates a firm and clear sense of direction. She understands the needs of the residents and was seen really listening and empathising with residents. Money held by the home for residents was sampled and appeared in good order. Record keeping is in order with all care records, staff records secure and up to date. Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 15 All the required safety checks are in order with portable appliance testing due to take place the following week. A risk assessment of the homes safe working practices is to be completed. A carpet gripper across a downstairs bathroom floor needs repair. Alternative air fresheners should be sought so as to reduce accessibility to residents. These changes will ensure residents and staff are safe and protected. Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 16 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x x x x x 3 x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 x 3 3 3 3 2 Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 13 Requirement The Registered Person shall ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety: Produce a risk assessment for maintaining safe working practices. A carpet gripper across a downstairs bathroom floor must be made safe. Timescale for action 15/11/05 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 OP38 Good Practice Recommendations To consider alternative air fresheners that are safe to use. Woodway House DS0000001842.V262689.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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