Inspection on 10/08/06 for Woodway House

This inspection was carried out on 10th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodway House 12/03/09

Woodway House 01/11/05

Woodway House 21/06/05

Woodway House 09/12/04

Woodway House 14/06/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Woodway House 11 Enderby Road Blaby Leicestershire LE8 4GD Lead Inspector Thea Richards Unannounced Inspection 10th August 2006 10:00 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 Woodway House DS0000001842.V305943.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. Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 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.V305943.R01.S.doc Version 5.2 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. 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 home is a large spacious house on two levels, which has been converted for its existing use. There are four lounges available, which enable the residents to have a choice in where they sit, together with a good-sized dining area. A no smoking policy operates in the home, although residents who smoke are able to do so in the patio area. The home is well located near the centre of Blaby and there is easy access for public and private transport. Residents can gain access to a variety of shops and other amenities in the village or Leicester city centre. The premises consist of two floors accessible by use of the stairs and a passenger lift. The residents’ bedrooms are clean, bright and airy and are personalised with their own belongings. An enclosed courtyard is available with seating for residents who wish to sit outside. There is information available in the reception area including the Registration certificate together with the homes’ complaints policy. The latest copy of the Inspection report from the Commission for Social Care Inspection is available in the managers’ office. The current fee level ranges from £390.00pw to £415.00pw. There are additional costs for individual expenses such as personal toiletries, optician, hairdressing and some recreational activities Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of the home that was concluded with an unannounced visit to the home. Prior to the visit the inspector spent half a day reviewing the previous inspection report and information relating to the home received since the last inspection on the first of November 2005. The visit took place on the eleventh of August 2006 from 09:30 and lasted four and a half hours. During the course of the visit the inspector checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that the inspector looked at the care provided to two residents living at the home, by speaking with the residents themselves; talking with staff supporting their care; checking records relating to their health and welfare and viewing their personal accommodation (with their consent) as well as communal living areas. The inspector also checked other issues relating to the running of the home including health and safety, management and staffing. During the visit the inspector spoke with other residents in the home, staff, visitors and the manager. The inspector also observed care practices when staff assisted residents. What the service does well: All the residents, visitors and staff spoken with were very happy and positive about the home, the food, activities and the care given. The staff appeared to be committed to the care of the residents and were observed spending individual time with them helping them with care needs, talking with them and giving a resident a manicure. Staffing levels and the skill mix were found to be good and the staff were found to be knowledgeable about the safeguarding of adults the medication policy and the care needs of the residents. This ensures that the residents receive appropriate care delivered safely by knowledgeable staff. The activities that are arranged for the residents, particularly the ‘movement to music’ class are appropriate for and much enjoyed by the residents. ‘ I love being here, it couldn’t be better’ Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Woodway House DS0000001842.V305943.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 Woodway House DS0000001842.V305943.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): 2, 3. 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using the available evidence. Residents’ needs are well assessed prior to moving into the home by the completion of a pre-admission assessment by a trained member of staff or by Social Services. EVIDENCE: The inspector checked the care records of two residents who were case tracked. Both residents have a contract and a statement of terms present in in their files. Completed pre-admission assessments are present in the residents files, identifying their needs, prior to their admission to the home. Care plans reflected the needs of the resident identified in the pre-admission assessment. Staff spoken with said that they were aware of the residents’ needs prior to them moving into the home. The residents and the visitors spoken with confirmed that they had had the opportunity of visiting the home prior to moving in. Woodway House DS0000001842.V305943.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 group is good. This judgement is made using the available evidence including a visit to the service. The staff fully meet the current care needs of the residents. EVIDENCE: The care plans for two residents were looked at and found to contain good individual evidence of care, which reflects the care being given to the residents. There is evidence of the involvement of G.P.s, district nurses, chiropodist, optician and dentist present in the care plans. Care plans identified care needs which were regularly updated which means that the staff are aware of the residents current needs and therefore will deliver the correct care. There are entries for the resident’s involvement in activities in the daily record of care which was up to date. Staff spoken with were aware of the current care needs of the residents. Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 10 There are risk assessments present in the residents care plans, however consideration could be given to making them more comprehensive to enable the staff to deliver safer care for the identified risks. Medication records for the case tracked residents were in order. Staff were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. There are no residents currently administering their own medication. The inspector observed the residents being treated with dignity and respect when staff spoke with them, assisted them at coffee and lunchtime and provided care for them. Residents spoken with were happy with the way staff treated them and said that they were very kind. Two visitors spoken with on the day of the visit were very happy with the level of individual care being given to and the way in which their relatives were treated. Woodway House DS0000001842.V305943.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 group is good. This judgement is made using available evidence including a visit to the service. Residents have their social, religious and nutritional needs met. EVIDENCE: Care plans and daily records reflect evidence of choices made by the resident in their daily lives, their social activity and meals. There is evidence in the daily records that the residents spiritual, social and nutritional needs are being addressed, discussion with the residents, visitors and the staff confirmed the availability and provision in these areas. There was documentation available, confirming that residents were taking part in varied activities in the home. On the day of the visit most of the residents were observed taking part enthusiastically in a ‘movement to music’ class, which included elements of mental stimulation with memory games, colours and money. There was good personal interaction between the staff and the residents seen and individual activity such as a manicure was taking place. On the day of the visit residents were observed sitting in a choice of four lounges, listening to music, watching the television or just being quiet. Residents spoken with said that they enjoyed the activity in the home and thought that there was sufficient and enough variety. There are outings arranged when a vehicle is Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 12 hired and as the home is in an excellent position close to the village centre both the staff and families are able to take the residents out locally, one of the residents’ was observed being taken out to the local coffee shop on the day of the visit. There is a choice of meals available and diabetic meals are provided, if there was a need for other diets such as vegetarian the home would be able to provide them. Residents spoken with all said that the food was very good and were happy with the choices which they could make. A visitor spoken with told the inspector that they are able to have a meal with their relative if they wished to and enjoyed the food if they did. Visitors are made very welcome in the home and some take their relatives out regularly. This was confirmed by visitors spoken with who told the inspector that they were made very welcome at any time. The residents are invited to meetings and are seen daily in a one to one situation which enables them to make their views known. Families and friends are invited to the residents’ meetings to express their opinions, are seen on a one to one basis and are invited to complete a questionaire to express their views. The local vicar visits every third Sunday to hold a service in the home, which most of the residents take part in and they regularly receive visitors from the church. There are currently no residents in the home with other than the Anglican faith, but the home has always in the past ensured that any residents within a differing faith are accommodated. There are currently no residents living in the home with differing cultural or ethnicity needs. Comments from the residents included ‘ I love being here, it couldn’t be better’ Woodway House DS0000001842.V305943.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 group is good. This judgement has been made using available evidence including a visit to the service. There systems in place to support and protect residents and staff are knowlegeable about the processes. EVIDENCE: There is a complaints policy in place and only one concern has been recorded in the home since the last inspection. This was dealt with and resolved in an appropriate manner. The residents spoken with were happy that they would speak to the manager or a member of staff, if they had a problem. Visitors spoken with on the day of the visit said that whilst they had had no occasion to do so, they were aware of the procedure to complain and would have no concerns about doing so. The Commission for Social Care Inspection has received no complaints or concerns since the last inspection on the first of November 2005. There is evidence of training in safeguarding adults having been received by staff and staff spoken with were knowledgeable about safeguarding adults and would be prepared to ‘whistle blow’ if they felt that there was a problem,they were aware of the procedure to follow. These policies ensure that the residents are protected from harm. Woodway House DS0000001842.V305943.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, 23, 24, 25, 26 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents live in a safe, clean and homely environment. EVIDENCE: The Registration certificate from the Commission for Social care Inspection was displayed in the reception area. The latest report was available in the managers’ office. The communal areas including the lounges and dining room provide a homely and comfortable environment for the residents to live in. There was a choice of chairs both in the lounges and the dining room which enables the residents to sit in an appropriately sized chair. The bedrooms provided good accommodation and had been personalised with the resident’s belongings. They were clean and safe and the room that was shared had adequate provision for the privacy of the residents. Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 15 A shower room on the first floor appeared to be being used as a store area and had no shower curtain or bath mat, this either needs to be locked if it is being used as a storage area or be made safe to use as shower room. A bathroom on the ground floor contained unamed toiletries which could present a health and safety hazard to the residents and an infection control risk if being used by more than one resident. There is level access to a patio area with chairs and a table which enables the residents to sit outside. Records for fire-drills and testing of water temperatures were found to be out of date. The manager has subsequently forwarded documentary evidence to the Commission of Social Care confirming that these areas are up-to-date. An environmental health visit was taking place on the day of the visit and there were some areas of concern identified, which the manager cofirmed would be addressed. Woodway House DS0000001842.V305943.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 group is good. This judgement is made using the available evidence including a visit to the service. The residents’ needs are met and their safety is protected by the staff. EVIDENCE: There is evidence of a good skill mix of staff to give the care identified for the residents needs and the number of staff on duty reflected the duty rota. The residents, staff and visitors spoken with felt that there were always sufficient numbers of staff on duty to cater for their needs. Two staff files were viewed by the inspector and the required documentation was complete in both files. There was evidence of a robust recruitment policy in place which ensures the safety of the residents. There was evidence of staff training in a separate file and staff spoken with confirmed that they received regular training including in areas such as dementia training and infection control in addition to the mandatory training required which enhances the quality of the care given to the residents. Nine staff had a National Vocational Qualification at level two or above and two more were about to commence. The National Vocational Qualification is a qualification for care staff to ensure that they receive appropriate training in the needs of the resident group which they are caring for. The manager has completed a Registered Managers’ Award which is a requirement for managers and is achieved through the National Vocational Qualification system. Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 17 There was evidence that staff supervision was in place which gives staff time with their line manager to discuss their work and training needs to enhance the quality of care given to the residents. . Woodway House DS0000001842.V305943.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 group is good. This judgement has been made using the available evidence including a visit to the service. Residents live in a home, which provides good staffing for their needs, with basic safety and protection in place. EVIDENCE: The manager was available throughout the visit to the home . The manager has worked in the home for fourteen years and has been the manager for five years. She has completed the Registered managers award and is enthusiastic in identifying training, both for herself and in supporting her staffs’ training. The manager holds regular meetings with the residents and their families in addition to one to one discussions with them to ensure that the home is providing the service that they need and require. A quality questionaire is regularly distributed to residents and families to gain their views. The manager works alongside the staff in caring for the residents which enables Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 19 her to supervise the staff and to ensure that the residents’ needs are being met. Residents are protected by the recruitment policy, with the obtaining of relevant documentation such as references, identification and criminal records bureau checks. Staff were being given appropriate training to look after the residents both in care needs and health and safety issues. This was confirmed by available documentation, the manager and by staff spoken with. Residents’ finances are handled by their families with some monies held on their behalf for incidental expenses. This is handled by the manager and the administrator with good records in place. There are records of expenditure available in the home. Residents needs are met with a good working relationship with the district nurses who will supply equipment for the use of the residents. The homes owner supplies equipment if needed and provides both financial and physical resources for recreational activity. The records confirming that all health and safety requirements are being met to maintain a safe environment for the residents and the staff are up to date which enhances their safety in the home. There were no visiting professional staff in the home on the day of the visit to enable the inspector to discuss their views of the home. The manager told the inspector that they had an excellent relationship with the Doctors and the District Nurses and in fact, they referred residents to the home, particularly for respite stays. Woodway House DS0000001842.V305943.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X 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 2 3 X X 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 3 X 3 X X 3 Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? None 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. Standard Regulation Requirement Timescale for action 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. 2. 3. Refer to Standard OP7 OP19 OP19 Good Practice Recommendations The registered person should give consideration to ensuring that risk assessments are sufficiently comprehensive to reduce the residents’ identified risks. The registered person should ensure that the identified first floor bathroom is made suitable for its intended use. The registered person should ensure that the personal toiletries located in the identified ground floor bathroom are removed to ensure that health and safety and infection control is maintained for the residents. Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 22 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 © 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 Woodway House DS0000001842.V305943.R01.S.doc Version 5.2 Page 23 - 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!