Inspection on 21/06/05 for Woodway House

This inspection was carried out on 21st June 2005.

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 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 10/08/06

Woodway House 01/11/05

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 Helen Abel Unannounced 21st June 2005, 3:15 pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodway House Address 11 Enderby Road Blaby Leicestershire LE8 4GD 0116 2773890 0116 2773530 None Mr Shabbir Hakimuddin Kaka Mrs Naseem Shabbir Kaka Mrs Ruth Shardlow Care Home 32 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of Dementia (6), Mental Disorder (6), Old Age (26) registration, with number of places Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th December 2004 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 C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced during a week day afternoon for around four hours. We spoke with five residents, two staff and the Registered Manager. A full tour of the premises took place, and records, policies and procedures were examined. What the service does well: What has improved since the last inspection? Risk assessments for residents have been updated on care plans and now include fuller information around all aspects of care for residents to be met by care staff. Monthly weighing of residents now takes place with any appropriate action taken and recorded. A revised accident procedure is in place with particular attention around bumps to resident’s heads. Arrangements for the safe administration of medication have improved this is supported by staff attending accredited training. Consultation now takes place with residents or family members around their wishes for death and dying. A regular religious service in the home for residents is due to commence. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3, Written information is available to new residents to make an informed choice about life at the home. The assessment system for new residents is not fully implemented. EVIDENCE: The Statement of Purpose is available to new residents and is well presented and easy to read. Some updating of this document is still required. An assessment is completed for any new residents coming to live in the home. The assessment format should be updated to include the signature of the resident, and other family / friends present and consulted with, as part of the assessment process. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9, The standard of care documentation does not indicate that health, personal and social care needs are met; which leaves the residents unprotected. EVIDENCE: Care plans have developed since the last inspection and detail more information around the care needs required. Monthly reviews take place of each resident’s care and any changes acted upon. An incident took place between two residents resulting in one of the residents being affected by the incident. Information was recorded in one residents care records, but not for the other resident. It is recommended a written daily entry be recorded for each resident to demonstrate their care needs and any other information. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 10 The records indicated that access to healthcare professionals was facilitated, as were visits to other specialists. Residents are weighed monthly with a written record of their weight held on their care plan. The pressure relieving records for one resident were examined and it was noted that the charts were poorly completed although in practice staff were regularly re-positioning the resident and their skin was well maintained. Appropriate equipment had been provided. It is recommended that written procedures and practice is reviewed in respect of the ongoing prevention of pressure sores. The Registered Manager confirmed this would be done immediately. Printed information was passed to the Registered Manager around risk assessments for bed rails. The medication storage areas and medication records were well organised. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15, There are sufficient social and cultural religious and recreational interests to meet the expectations and preferences of residents. Residents receive a wholesome and appealing diet in pleasant surroundings. EVIDENCE: Bingo sessions are held weekly and indoor games are available. Regular trips in the summer months are organised to pubs, boat trips, and places of interest. Some residents were observed going out to local shops with relatives. The Registered Manager has just arranged a religious service to be performed regularly at the home. The hairdresser was busy with residents on the day of inspection. It was agreed with the Registered Manager the television would be moved from the top of the wardrobe to a more appropriate position for two residents receiving care in a shared room. This would enable them to view the television more comfortably. Visiting hours are at any time between 8am to 10pm and families and friends were seen to be visiting without restriction. Positive interactions were observed between staff and relatives. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 12 A Residents Charter of Rights is held in the Statement of Purpose. This confirms the resident’s rights to personal independence, choice and for making their own decisions. Residents were observed all around the home in their own bedrooms, in one of the four lounges, dining room and sitting talking with staff or each other. Other residents had gone out with relatives. The atmosphere was very relaxed and informal. Tea was being served during the afternoon of the inspection. There was a wide range of choice served. One resident asked for another helping of dessert and said, “the tea is very good”. The food storage areas are kept in an orderly and organised manner with clear dating of food products displayed. High standards of hygiene are maintained throughout the kitchen area. Alcoholic drinks are restricted for some residents. They had been served out covered and labelled up ready for serving at the end of the day. From the morning they had been sitting in a sunny position on the kitchen windowsill. It is recommended once the residents alcoholic drinks are served they should be kept in the pantry where it is cooler. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 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 standard(s) 18 Policies and procedures are in place ensuring a proper response to any suspicion or allegation of abuse. EVIDENCE: Policies and procedures around protecting adults are held in the home. Further guidance is available in the staff Induction and through National Vocational Qualification training. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 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 standard(s) 19, 20, 21, 22,24,25, There are a number of matters, which put people at risk of serious harm and do not provide safe and comfortable surroundings in which to live. EVIDENCE: Since the last inspection requirements were made around preventing risks from scalding and providing water close to 43.c. in all areas accessible to residents. These same aspects still require attention: • • • The following water outlets were too hot: Room 30 60.c and rising. Bathroom next to room 30 wash hand basin 60.c and rising. Room 8 wash hand basin 58.c and rising. There was no hot water available in bathroom next to room 30, shower outlet. Rooms 5, 9, 10 and 25 had wash hand basin temperatures between 3839.c. This is too low and should be around 43.c C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 15 Woodway House • • In the bathroom next to room 30 a wooden lamp was left in the middle of the bathroom, an old chest of drawers looked worn and shabby and should be disposed of. There was no shower curtain or non- slip mats in the shower area. All these aspects create a poor impression of the home. Thermometers for checking bath/shower water temperatures were not available although signs in bathrooms instructed staff to test water temperatures. The Registered Manager confirmed that regular water testing was taking place with concerns passed to the Registered Provider to action. Some plumbing repair work had been recently undertaken. The green bathroom had a mix of toiletries stored on a shelf unlabeled belonging to different residents. It is recommended each resident have a separate toiletries container made up and held in their rooms. This can be brought to the communal bathroom when they need it. This will reduce the risk of items getting lost or used by mistake. Resident’s rooms were clean and comfortable and all individually personalized. Some residents had brought in their own furniture, pictures and mirrors. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29,30 Good recruitment policies and procedures support and protect residents. Individual staff training programmes are in place ensuring staff are competent to do their jobs. EVIDENCE: New staff will be receiving a certified staff Induction that equips them with core skills in care practices. Staff recruitment records are in order with criminal record checks kept up to date. Staff receive ongoing training in a range of care practices and through National Vocational Qualification Training (NVQ’s). Over 50 of the care staff have obtained a NVQ at level 2 or above. Recent training has been around Infection Control, Medication Management and Continence Care. Care staff are due to start a distance-learning course in Dementia Care. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 The person in charge is fit and able to discharge her duties as the Registered Manager. The home is run in the best interests of the residents. EVIDENCE: The Registered Manager has over ten years experience at the home as the manager and has recently completed her National Vocational Qualification in Management level 4. The Registered Manager attends all care training with her staff group and is also a trained First Aider. Residents spoken with confirmed, “You couldn’t be in a better place”. “Meals are very good you are well looked after. I am happy here”. Feedback from residents about care in the home is included in the Statement of Purpose. Residents were observed walking around to find the Registered Manager and telling her their problems. One resident was distressed about items of clothing going missing. The Registered Manager then went to off to help resolve the issue for the resident. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 18 In respect of the regulatory issues raised at the inspection the Registered Manager contacted the CSCI the following day to confirm all requirements and recommendations had been immediately put in place and this is commended. Information was shared with the Manager around meeting new asbestos legislation; a requirement was made. Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 2 3 3 3 x 3 3 x STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 x 3 x x x x 2 Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement Timescale for action 21st July 2005 2. 19 13 The assessment format should be updated to include the signature of the resident, and other family / friends present and consulted with, as part of the assessment process. 28th July The Registered Person shall ensure all parts of the home to 2005 which residents have access are so far as reasonably practicable, free from hazards to their safety. 1. The following water outlets were too hot: Room 30, 60.c and rising. Bathroom next to room 30 the wash hand basin was 60.c and rising. Room 8 wash hand basin was 58.c and rising. 2.There was no hot water available in bathroom next to room 30, shower outlet. 3.Rooms 5, 9, 10 and 25 had wash hand basin temperatures between 38-39.c. This is too low and should be around 43.c. (All items 1-4 were made as Immediate Requirements on the day of inspection) . Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 21 4.In the bathroom next to room 30 a wooden lamp was left in the middle of the bathroom; an old chest of drawers was present and looked worn and shabby and should be disposed of; there was no shower curtain or nonslip mats in the shower area. All these aspects create a poor impression of the home. 5.Thermometers for checking bath/shower water temperatures were not available although printed signs in bathrooms instructed staff to test bath/shower water temperatures. 3. 19 23 Ensure asbestos legislation is 1st met. Control of Asbestos at Work September Regulations 2002. Identify, 2005 assess and manage any asbestos containing materials on the premises. 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 1 Good Practice Recommendations It is recommended the Registered Provider provide open and transparent information in the Statement of Purpose of the ophthalmologist care he would be able to offer. Service users would be given the choice to keep their own optician, use a NHS one or utilise the Registered Providers optician services. The service users decision should be recorded in the service users care plan. (This was previously agreed with the CSCI at the 14th June 2004 inspection but has not been acted on). It is recommended a written daily entry be recorded for each resident, to demonstrate their care needs and any other relevant information 2. 7 Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 22 3. 4. 5. 6. 8 15 21 It is recommended written procedures and practices for the preventation of pressure sores are reviewed It is recommended once residents alcoholic drinks are served they should be kept in the pantry where it is cooler It is recommended each resident have their own toiletries Woodway House C51 S1842 Woodway V233265 200605.doc Version 1.30 Page 23 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire 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. 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