Inspection on 28/11/06 for Woolnough House

This inspection was carried out on 28th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Woolnough House 24/09/08

Woolnough House 31/10/07

Woolnough House 29/03/06

Woolnough House 06/12/05

Woolnough House 24/02/05

Woolnough House 10/08/04

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Hawkhills

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Woolnough House Woolnough House 52 Woolnough Avenue Tang Hall York North Yorkshire YO10 3RE Lead Inspector Jo Bell Key Unannounced Inspection 28th November 2006 09:00 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 Woolnough House DS0000034896.V322134.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. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woolnough House Address Woolnough House 52 Woolnough Avenue Tang Hall York North Yorkshire YO10 3RE 01904 413656 01904 431755 EPHwoolnough@york.gov.uk 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) City of York Council *** Post Vacant *** Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29th March 2006 Brief Description of the Service: Woolnough House provides personnel care and accommodation for up to 35 older people and is owned and managed by City Of York Council. Nursing care is not provided. Woolnough House was purpose-built approximately 40 years ago and is located in the Tang Hall area of the city. The centre of York is about 2 miles from the home. The scales of charges are £426.92 per week. There are nearby shops and public houses. Accommodation is provided in single rooms on two floors. The upper floors are accessed by a passenger lift. There is a small car park to the front of the home. The home is waiting for a new manager to start, who will then apply to the Commission for Social Care Inspection for registration. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of the service took place on Tuesday 28th November 2006. Prior to the visit a pre-inspection questionnaire was completed and surveys were sent to healthcare professionals, service users and relatives. This was to ascertain their views about the service offered at Woolnough. The visit lasted for five hours during which time service users, staff and relatives were spoken with. Care practices were observed and documentation relating to service users was examined. Discussions took place with the temporary manager regarding quality assurance, health and safety, and medication. The home has a pleasant atmosphere with good standards of care being provided. Service users made positive comments regarding the staff, the food and the environment they live in. Aspects of the care planning process and the activities provided need to be improved to ensure the outcome remains good for service users. The quality assurance system needs to be fully implemented to ensure views of service users are taken into account and these are acted upon where necessary. What the service does well: What has improved since the last inspection? No areas have improved since the last visit. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Woolnough House DS0000034896.V322134.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 Woolnough House DS0000034896.V322134.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable) Quality in this outcome area is good. Service users have their needs assessed prior to admission to ensure needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The assessments prior to admission are undertaken by a care manager, three of these were checked and were found to contain information relating to personal and social care. These were sufficiently detailed to understand the needs of each service user prior to coming into the home. One of the care leaders confirmed that the home also carry out their own assessments either when the service user is in hospital or at home. This is useful information to gather, however this is not always documented but passed to other staff verbally. A consistent approach to obtaining and recorded this information needs to take place. Woolnough House DS0000034896.V322134.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Whilst the quality of care is good, aspects of nutrition and medication need to be improved on, this will then have a positive effect on the outcomes for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were well cared for in the home, they looked clean and tidy with their hair washed and nails cut. One lady said ‘the staff are just lovely they really know how to care’. Care plans were inspected and generally these had detailed information in which covered all aspects of care, this was reviewed and evaluated on a monthly basis. It was evident that a greater understanding of the term ‘identified need’ is required. One care plan repeatedly had the term ‘no issues’ though problems had been identified. One service user had a continence problem which had conflicting information, which made it difficult to understand the current position. Six service user surveys were returned, only had commented on the care being slow. This was discussed with the manager and a review is taking place to address this. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 10 The home can access GPs, Dentist, chiropody and healthcare through the district nurses, continence advisor and local hospital. Comment cards were received from GPs and one stated ‘an excellent facility, local people caring and understanding local patients’ . Currently the home assesses service users nutrition through asking ‘likes and dislikes’. This information needs to be more detailed, some service users are not weighed and a specific assessment regarding nutrition needs to be implemented. This was discussed with the manager who is in the process of gathering this information for implementation in the near future. This was further evidenced by kitchen staff who were not aware of how to cater for staff who are under or over nourished, this is partly because some of the meals come ready prepared. (see also Standard 15) It was identified that staff did not always know why visits from the district nurse had taken place. For example one new service user had needed to have bloods taken, though this was documented the care leader did not know why this had been taken, or whether a result had been obtained, or the effect on the service user. The home is aware of how to record incidents/accidents and these are reported under Regulation 37 notifications. The medication system was inspected, a policy is in place for self medicating and for staff administering medication. Three medication charts were examined these were found to be correct. Service users spoken with commented that care leaders come and give them their medication. The fridge temperature is taken daily and staff have received training in this area which is accredited. The drugs trolley and medication was stored correctly. The controlled drugs were inspected and on one occasion the medication had been written in the book but no time or date had been recorded, though it had been administered. It was also evident that when a stock balance of, for example fentanyl patches takes place the actual amount of sachets are not counted, just the label on the box is checked. This needs to be addressed. The staff during the visit were keen to maintain privacy and dignity, service users were spoken with in a pleasant manner, and in discussions they confirmed how well they are treated and cared for. Woolnough House DS0000034896.V322134.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is adequate. Autonomy and choice is encouraged, and mealtimes are enjoyed by service users. However, more activities need to be provided to ensure service users are not bored. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were chatted with in the lounge, bedroom and dining area. Comment cards returned highlighted that more activities are needed, this was also confirmed by service users. Comments including ‘it is a long day’, ‘we are often bored’ and ‘we use to have activities but don’t anymore’ were made throughout the visit. The home currently does not have an activities organiser and this would be extremely beneficial. The pre-inspection questionnaire does however state that, entertainers organised with York Cares group takes place, and previous sherry afternoons and garden projects have taken place. Staff do encourage autonomy and choice and visitors sign in and out when they visit the home. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 12 Mealtimes were discussed. At lunchtime food looked appetising and service users were observed enjoying the main course and pudding. One lady was eating ham, roast potatoes and vegetables she said ‘the food is lovely’. The food is delivered from the hospital and the cook only makes homemade food on certain days of the week. Two kitchen staff were spoken with and it was evident that they were not aware of how to cater for service users who need their food fortifying, this is difficult because the food is mainly pre-prepared. The kitchen area is a good size and this was kept clean and tidy. The service users have access to a large dining area which feels spacious and is decorated well. Service users can eat either in the dining area, other communal areas or in their own room. Breakfast is served from 8.30am, lunch and evening meal are offered and supper commences at 7pm. Woolnough House DS0000034896.V322134.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. Service users are aware of how to complain, and they are treated in a respectful manner with staff understanding adult protection issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home have a complaints procedure in place with relevant details of who to contact should a concern arise. Service users spoke with said they would be happy to speak to care staff or the manager if they had any issues. No concerns were raised in the service user surveys, and the home has dealt with only one complaint since the last inspect The CSCI has not received any complaints. Staff have a good understanding of adult protection, they are aware of the City of York Council guidance and the no-secrets information. Service users confirmed that they are handled gently, are spoken to appropriately and are treated well by staff. Woolnough House DS0000034896.V322134.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. Service users live in a pleasant environment, which is clean and fresh smelling. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is purpose built and is maintained by City of York Council. Areas examined were clean and tidy and service users confirmed they liked living in this environment. There are a suitable number of communal areas (three), with four bathrooms and twelve toilets. Staff have undergone infection control training, and general assistants ensure the home is kept clean and pleasant smelling. The laundry area is adequate and service users said their clothes are washed and ironed and put back in their rooms. The sluice room is suitable for its purpose and staff are aware of different coloured bags to use for soiled and non soiled linen. Staff were observed wearing protective clothing and gloves where necessary. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. Service users are cared for by staff in adequate numbers who receive training which means service users needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a sufficient number of staff to care for the current client group. Both during the day and overnight. Though more staff would be beneficial when facilitating activities for service users. Service users had access to call bells and staff were prompt in answering these. Currently almost half of the care staff have completed an NVQ Level 2 or above in care, this ensures there is a consistent approach to caring and meeting needs. Three recruitment files were checked and these contained two written references, CRB and Protection of vulnerable adults information. Human resources are responsible for these files though the manager asks for copies of the application forms and references. The manager is aware of the recruitment practices needed to safely employ new staff. The home are introducing a new induction programme, this is equivalent to Skills for care (formerly TOPSS) and includes care practices, mandatory training and specific timescales for completing these areas. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate. Whilst service users best interests are generally met in a safe environment, there is no registered manager in place and the home needs stability to ensure there is a consistent approach when delivering all aspects of care. This will be enhanced by developing the quality assurance system further. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Currently the home is run by a temporary manager who has worked hard to maintain the homes standards. A new manager is due to start shortly and will need to be registered with the CSCI. Service users and staff were introduced to the new manager (she was visiting the home during the inspection). It was evident that changes had taken place in management which had unsettled the staff and some of the service users. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 17 Quality assurance in the home is starting to be implemented, though further work is needed to ensure the home is aware of the views and opinions of all the service users, this includes auditing of key areas and having an annual development plan. Residents and staff meetings need to take place on a regular basis. Service users finances were discussed, pocket money allowances are available and these are recorded on an individual basis. Three of these were checked and found to be accurate. Service users confirmed that this system is in operation. No concerns were raised regarding this issue. Health and safety in the home was inspected. The pre-inspection questionnaire gave some details of certificates that had been completed. The certificates checked at the site visit were environmental health, water temperatures, electrical wiring, gas safety and equipment checks for hoists. These were all found to be in date and no issues had been identified. Staff are aware that they need to attend mandatory training, this includes fire, moving and handling, health and safety, infection control, and first aid. Three staff files checked showed these are up to date. The home have a fire alarm test on a weekly basis and night staff attend three monthly fire training and day staff attend six monthly. When touring the premises emergency lighting was evident, fire zones, radiator covers in place, and water temperatures were checked and found to be within the normal range. Maintenance staff were visiting the home and checking the plumbing system. The home is forwarding a copy of the legionella compliance certificate as this was unavailable at the visit. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 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 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 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 1 x 2 x 3 x x 3 Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? N/A 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. OP3 2. OP7 15 Standard Regulation 14 Requirement The assessment carried out on service users by staff from the home must be documented for all staff to refer to. An understanding of the term ‘identified need’ must be understood by all staff and appropriate entries must be made in this section. Catering staff must understand how to modify food/drink to ensure service users who are under or over weight are catered for. Care staff need to have a clear system for obtaining nutritional information about service users, which then needs to be acted upon. The controlled drugs book must be completed correctly. When checking stock balances the amount of medication, not just the boxes need to be checked. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 20 Timescale for action 28/11/06 12/12/06 3. OP8 14 28/12/06 4. OP9 13 28/11/06 5. 6. OP12 OP31 16 9 A range of activities need to be offered to ensure service users are stimulated and not bored. The home must submit an application to have a registered manager in place 28/01/07 28/02/07 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 OP33 Good Practice Recommendations The quality assurance system should be fully implemented. Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Woolnough House DS0000034896.V322134.R01.S.doc Version 5.2 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. 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. 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