Inspection on 27/07/07 for Woolton Manor

This inspection was carried out on 27th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Woolton Manor 24/07/08

Woolton Manor 23/05/06

Woolton Manor 06/12/05

Woolton Manor 06/05/05

Woolton Manor 27/10/04

Woolton Manor 16/06/04

Woolton Manor 12/11/03

Woolton Manor 27/08/03

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

CARE HOMES FOR OLDER PEOPLE Woolton Manor Allerton Road Woolton Liverpool Merseyside L25 7TB Lead Inspector Jeanette Fielding Key Unannounced Inspection 27th July 2007 10:20 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 Woolton Manor DS0000025172.V336413.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. Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woolton Manor Address Allerton Road Woolton Liverpool Merseyside L25 7TB 0151 421 0801 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) wooltonmanor@btconnect.com Mr Abid Yousaf Chudary Margaret Jenkins Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66) of places Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing: Code N, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP The maximum number of people who can be accommodated is: 66. Date of last inspection 23rd May 2006 Brief Description of the Service: Woolton Manor is a fine period residence set in its own grounds close to the picturesque village of Woolton, Liverpool. The home offers 66 single bedrooms, 65 of which benefiting from en-suite facilities. For those service users who choose to share, two rooms would be provided with the second room being a sitting room. There are two large lounges; two separate dining rooms, a quiet lounge and a garden/patio area. A separate smoking room is set-aside for clients. Fees at Woolton Manor range from £335 to £425 plus the nursing fee. Outside the grounds, all the local village facilities, shops, post office and bus routes are available within easy walking distance. Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted in one day over a period of eight hours. During the inspection, the care plans for a selection of service users were inspected together with records held in relation to the care afforded to service users. Staff records were inspected to ensure that recruitment procedures are robust to ensure the protection of service users. Discussion took place with the owner, manager, staff, service users and visitors to the home. A full tour of the premises was undertaken. What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 6 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 Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 7 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): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Full information regarding prospective service users needs is gathered prior to service users admission to the home to enable staff to be fully informed about their care needs. EVIDENCE: The home’s Statement of Purpose and Service User Guide have recently been reviewed and updated to reflect changes that have taken place. These documents are now detailed and provide current and prospective service users will full information regarding the homes’ services and facilities. Copies of the documents are available from the home on request. Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 8 A sample of care files were inspected from both the residential and nursing areas of the home to ensure that pre-admission assessments had been undertaken and were in place. All files were found to contain comprehensive pre-admission assessments to clearly identify service users needs and wishes and to demonstrate that the home was able to meet those needs and wishes. The format for the pre-admission assessment forms is regularly reviewed and updated to ensure that any necessary equipment or facilities are identified and arrangements put in place to provide these prior to the service users admission to the home. The home does not offer intermediate care. Woolton Manor DS0000025172.V336413.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): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans are prepared to enable the staff to identify and meet the service users individual needs and preferences. EVIDENCE: Individual care plans are prepared for all service users to give staff full information regarding the care required to give the service users a high quality of life. The plans include full risk assessments and risk management plans to remove or reduce any potential risk to the service user. Assessments are undertaken for the use of bed rails and a signed agreement is made for the use of these with the service user or their next of kin. Care plans are prepared in relation to all aspects of daily living and provide staff with full information to enable them to meet the service users needs. These were found to be detailed and informative. Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 10 Moving and handling assessments clearly identify the safest method of assisting service users and give details of any equipment necessary and the number of staff required to assist the service user. Preferences regarding the service users choice of gender of staff to provide personal care is obtained and every effort made to ensure that these preferences are met. Records are maintained of visits to and by other healthcare professionals including GP, dietician, optician, tissue viability specialist nurse, continence advisor and chiropodist. Advice given by these professionals is recorded and care plans amended to ensure that the appropriate level of care is given. Daily records are completed by the staff to provide evidence of the actual care given. These records are detailed and informative. Records are also held of conversations held with relevant persons i.e. family members and advocates. Wound management if required on the residential unit is managed by the District Nursing Service and evidence was seen that there is a good relationship with the service with wounds being referred and seen promptly. Examination of wound management records in the nursing unit has improved since the last inspection with full details of the progress of the wounds now being held. Two separate medications rooms are provided within the home, one for service users who are accommodated for personal care and one for service users who are accommodated for nursing care. Arrangements are currently in place to relocate the nursing unit medications room as it has not been possible to maintain the temperature of the current room at an appropriate temperature for the medications stored. Medication Administration Record sheets were found to be completed accurately as required and were up to date. Medications are securely stored and all storage areas were clean and organised. Regular audits on medications are undertaken and the method used for the audits is being reviewed to provide a clearer record of the outcomes of the audits and to further ensure that service users are protected. Appropriate arrangements are in place for the disposal of unwanted medications and detailed records of these are held. Training has been given to care assistants who administer medications to ensure that they are competent and can administer medications in line with the homes policy and procedure. Records are held of this training. All service users are accommodated in single bedrooms and personal care is given in their room or in the bathroom as appropriate to ensure that privacy and dignity are protected. Staff were observed to knock on service users bedroom doors and to wait for an answer prior to entering. Woolton Manor DS0000025172.V336413.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 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A wide range of activities are available which provide service users with stimulation to promote social interaction. EVIDENCE: Detailed information is gathered from service users on admission to the home regarding their past life and the social activities that they had previously enjoyed. It was evident from discussion with service users that the staff strived to provide a varied social activities programme in line with their individual preferences and abilities. The home employs an activities coordinator who works 30 hours each week over five days. The programme of activities is displayed in the home and includes both in house stimulation and trips out. Service users confirmed that there is a good range of activities and that they are free to choose whether or not they participate. Group activities are provided together with one to one stimulation for those who do not wish to or are unable to participate in group events. Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 12 On the day of the inspection, a sing-a-long was underway and this was observed to be well attended and service users spoken to after the activity said that they really enjoyed and had a lovely time. A record of activities that service users participate in is held. Ministers from two churches make regular visits to the home and provide services to group or individual service users on request. Visitors are welcome to visit the home at any time and a high number of visitors were observed at the time of the inspection. Visitors spoken to during the inspection were extremely complimentary about the staff and the care that they gave. One relative said that staff were knowledgeable about the care that her relative needed and were always on hand whenever they were needed. Meals are served in the dining room or in the service users bedroom as they wish. The menu provides evidence that a well balanced diet is offered and a choice of meal is always available. The meal served during the inspection was attractively served and looked and smelled appetising. Service users said that the food was really good and confirmed that they could choose from the menu or request a particular favourite. Special diets can be provided on the advice of the GP or dietician or on request of the service user. The dining tables were observed to be attractively laid with condiments and appropriate cutlery. Woolton Manor DS0000025172.V336413.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a good knowledge and understanding of Adult Protection issues to protect service users from harm or abuse. EVIDENCE: The home has developed a comprehensive complaints procedure which is detailed in the Statement of Purpose and Service User Guide and is also displayed on notice boards within the home. The procedure gives service users and visitors the details of the person to whom complaints should be made and the timescale in which the complaint will be investigated and responded to within. Three complaints have been made against the home in the last twelve months and all were fully investigated and dealt with appropriately. All staff have been given training on the Protection of Vulnerable Adults and are fully aware of the different types of abuse and of the action to be taken in the event of it being suspected to ensure that service users are protected. Staff spoken to during the inspection were able to demonstrate that they were aware of the procedure to be followed. Woolton Manor DS0000025172.V336413.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, 22, 24 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Continued investment has improved the appearance of the home creating a comfortable and safe environment for those living there and visiting. EVIDENCE: Service users are all accommodated in single bedrooms, all, with the exception of one, having en suite facilities. The bedrooms are spacious and bright and it is evident that every effort has been made to assist service users to personalise their rooms with pictures, photographs and items of memorabilia. Some service users have chosen to provide items of furniture to make their room more homely. Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 15 Since the last inspection, both lounges have been recarpetted and fitted with large plasma screen televisions. The kitchen units in the small dining room have been fitted with new units and this area is now clean, bright and organised. New dining chairs have been ordered and delivery is awaited. The planned programme of redecoration and improvements continues to take place with a number of bedrooms having been redecorated and new cantilever tables ordered for bedrooms. Communal areas are spacious and bright and the corridors are wide. Armchairs have been provided in the corridor on the ground floor and it was evident that service users enjoy sitting in this area. One service user said that she liked sitting in the corridor because she could see everyone who came and went and had the chance to chat with everyone who passed. Specialised equipment such as a lift, assisted bath and shower rooms, hoists and appropriate toilet aids are provided to assist service users and maximise their independence. All areas of the home were found to be clean and fresh. No unpleasant odours were noted. The home has recently increased the number of domestic staff hours by 30 per week and this has clearly improved the standards within the home. The home is set in extensive grounds and service users are free to use these areas subject to a risk assessment to ensure that they are safe. Woolton Manor DS0000025172.V336413.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is supported by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The home is staffed as two separate units, the nursing and the residential units. In the nursing unit, a qualified nurse is on duty at all times who is supported by six care staff during the morning, five care staff during the afternoon and evening and two care staff at night. In the residential unit, a senior care assistant is on duty at all times who is supported by five care staff during the morning, four care staff during the afternoon and evening and two care staff at night. The staff rota shows that the home is fully staffed at all times. The home has a robust recruitment procedure which requires prospective staff to complete an application form prior to being called for interview. Two references are taken and all applicants are required to have a Criminal Record Bureau and Protection of Vulnerable Adults registers checked to ensure that Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 17 service users are protected. A record of the issues discussed at interview are held and evidence of qualifications are required to be produced. Staff records were inspected and were found to be extremely well organised with evidence of training undertaken held on all files. New staff are required to complete an induction training programme followed by a foundation training programme. Evidence of this training is held on their files. An extremely high programme of training has been followed since the last inspection including the Protection of Vulnerable Adults, health and safety, moving and handling, fire safety, infection control, food hygiene and dementia care. Qualified nurses are given training specific to the nursing needs of service users, with many having now completed an update on the use of syringe drivers. NVQ training has been encouraged and eight staff are now working towards level 2 and one is working towards level 3. A full programme of training has also been planned for the next few months and the manager was able to provide evidence of this. Woolton Manor DS0000025172.V336413.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has a clear development plan for the home which she has effectively communicated to service users, staff and relatives. EVIDENCE: The registered manager of the home is experienced and has achieved NVQ qualifications in management at both level 4 and level 5. She is supported by a Deputy Manager, a qualified nurse and a Residential Care Manager who has also achieved NVQ to a high level. Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 19 The manager is also well supported by the owner of the home who visits most days each week. Staff meetings are held regularly and provide a forum for the dissemination of information and an opportunity for staff to suggest ideas and areas for improvement. The meetings are well attended. Relatives meetings are held regularly and the manager speaks with service users on a one to one basis. Staff supervision is given on a regular basis to identify training needs and to promote good practice within the home. The home does not attend to any of the service users finances and this is dealt with by relatives or advocates. Safety checks are made on the premises and all equipment and certificates of these were found to be in place and up to date. It was evident from inspection of records, discussion with management, staff and service users that the home is run in the best interests of the service users. One service user said that this was her home now, everyone was lovely and she got the best of everything. She said that she was free to do whatever she wanted and that the staff supported her in this. Woolton Manor DS0000025172.V336413.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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X 3 X 4 X 4 STAFFING3 Standard No Score 27 3 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations Woolton Manor DS0000025172.V336413.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Merseyside Area Office 2nd Floor, South Wing Burlington House Crosby Road North Waterloo L22 0LG 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 Woolton Manor DS0000025172.V336413.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. 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