Inspection on 06/12/05 for Woolton Manor

This inspection was carried out on 6th December 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woolton Manor 24/07/08

Woolton Manor 27/07/07

Woolton Manor 23/05/06

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 Les Smith Unannounced Inspection 6th December 2005 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 Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 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) Mr Abid Yousaf Chudary Care Home 70 Category(ies) of Old age, not falling within any other category registration, with number (66) of places Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 31 Nursing and 35 Personal Care within an overall total of 66 Date of last inspection 6th May 2005 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 bedrooms, mainly single, with the majority of rooms benefiting from en-suite facilities. For those service users who choose to share, a small selection of twin bedded rooms is offered. 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. Outside the grounds, all the local village facilities, shops, post office and bus routes are available within easy walking distance. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and was conducted by two regulatory inspectors and a specialist pharmacy inspector. A full tour of the premises took place and records such as care plans, staff personnel files and policies and procedures were also examined. A number of staff, and residents were spoken to during the course of this inspection by all inspectors. 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. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 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.V272418.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5 Residents are only admitted to Woolton Manor following a full pre-admission assessment. This helps ensure that the residents receive the appropriate care based upon their assessed needs. EVIDENCE: The Residential Care Manager or the Deputy Manager assesses prospective residents before admission, in the absence of a Registered Manager. There were copies of Social Services assessments for all recently admitted residents, together with written assessments made by Woolton Manor staff. The home’s assessments should be signed and dated by the person who has made the assessment. Woolton Manor is currently registered for 35 people to receive personal care only (in other words they do not receive nursing care) but in fact there were 40 such residents in the home. The Registered Person needs to apply for a variation to the home’s registration as a matter of urgency to ensure that he is not in breach of the home’s conditions of registration. It is possible for the Commission to allow some flexibility in the conditions of registration to allow Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 8 for periodic changes in the ratio of nursing patients to those receiving personal care only. During the inspection some relatives of prospective residents visited the home to see if it was suitable. The pre-admission assessment includes a section for pre admission visits. Prospective residents are encouraged to visit before making a decision but are often too frail to do so. Woolton Manor does not provide intermediate care so standard 6 does not apply. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 There is a care planning system in place but residents’ needs are not always identified due to lack of completeness and review. The systems for ordering, storing, administering, recording and disposal of medications are poor and places service users at risk. EVIDENCE: Residents have care plans in place, some of them comprehensive, but not all of them covered all of the necessary points. One resident had a Waterlow score indicating possible risk of pressure sores but there was no care plan for tissue viability and skin care. It is important that care plans are based on the pre admission and post admission assessments and cover all relevant areas of the resident’s care. One assessment referred to the resident having had MRSA on admission but this was not dealt with in the care plan nor in a risk assessment. Fortunately the resident had recovered from the condition whilst in the care of the home. Not all necessary risk assessments had been carried out; for instance a number of residents had bed rails but no risk assessments had been completed. The officers in charge should consult the MHRA Medical Device Alerts on the use of cot rails in preparing risk assessments. In one case the Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 10 care plan stated that a repositioning regime was required but no turning chart was on file. It was not always evident that the information available was being built in to the care planning and reviewing process. For instance the reviews and care plan of one resident did not reflect the detailed information provided by the Skin Care Service. An amendment had been made to the care plan but it was neither signed nor dated. There was evidence that the home promptly refers residents with pressure ulcers to the Skin Care Service. Medication administration has been inspected by a specialist pharmacy inspector and will be the subject of a separate report. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 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 As far as possible residents have choice and flexibility in how they spend their day in the home, and participate in leisure activities according to their choice and preferences thereby promoting independence and individuality for each resident. Meals at Woolton Manor are good, offering choice and variety whilst catering for residents dietary needs or cultural preferences EVIDENCE: Woolton Manor employs an Activities Organiser for 30 hours a week; unfortunately at the time of the inspection she was providing some cover at another home owned by the Registered Person but this arrangement was due to finish in the near future. She arranges a full range of activities and keeps a detailed record of who takes part in the different sessions and which things the residents enjoy most. Activities include quizzes, bingo, ‘pampering’ (make up and nail care – apparently some of the male residents enjoy a manicure), discussions, exercise, sing-alongs (ranging from the thirties to Elvis Presley) and crafts. Occasional trips out are organised, for instance to Southport in the summer, but not as many local trips as would be possible if transport was more readily available. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 12 Visitors are welcome to Woolton Manor at any time and a number came to see their relatives and friends during the inspection. Residents said that they enjoy the food at Woolton Manor. A cooked breakfast is always available and the main meal of the day is served at teatime. Although there is no choice of main meal on the menu, a range of set alternatives is always available, including baked potatoes, sandwiches, soup and hot snacks. Residents choose their meal the day before and the chef said that he tries to meet requests that are not on the menu or the usual alternatives. For instance, on the day of the inspection one resident was having white fish instead of smoked haddock, which was the meal of the day. Lunch is also often a substantial cooked meal. The chef caters for special diets and these were displayed on a whiteboard in the kitchen. He was not entirely aware of the needs of one resident with specific religious needs and the management need to take care to ensure that catering staff is properly informed of all special diet requirements. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 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 Residents and their legal rights are protected by the policies and procedures in place for the management of complaints. EVIDENCE: The home has a well-publicised complaints procedure and keeps a record of complaints but they were not all recorded in sufficient detail. A record needs to be kept of any investigation carried out and action taken. The Commission for Social Care Inspection has investigated two complaints since the last inspection and the reports on the inspections carried out to investigate them are made available with this report. The Registered Person has responded to the reports and provided the Commission with satisfactory action plans. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 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, 21, 22, 23, 24, 25, 26 The overall fabric of the building is of a good standard, with most resident’s rooms being personalized to varying degrees. A programme of redecoration, maintenance, refurbishment and cleaning needs to address many issues to ensure a safe, comfortable and well-maintained environment for residents. EVIDENCE: Residential Unit Dirty linen left on floor Lounge carpet very badly stained with numerous cigarette burns Shade missing from wall light Fire door not closing Numerous extractor fans not working in en-suites and bathrooms Radiator control broken in room 2 Soiling on wallpaper in room 3 No covers for commodes in rooms 9 and 12A No waste bag in clinical waste bin in sluice Toilet seat broken in shower room Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 15 No cover on outlet drain in shower room Waste bin lid very soiled Cleaning store found left open Nursing Unit Electrical multiplugs in general use Carpet in lounge very stained Diffuser on strip light missing Fire doors wedged open Numerous extractor fans not working Covers missing for commodes Bowls missing from commodes Commode bowls dirty Shower not working in shower room Wheelchairs and commodes being stored in en-suite of room 44 No soap dispenser in room 50 No toilet roll holder in room 64 Bed rails in use without bumpers in room 68. (Bumpers were stacked in corner of room) and no toilet roll holder in en-suite Room 57 used by two members of staff (1 bed plus mattress on floor) No lid on bin in bathroom No toilet roll holder in room 52 Sluice not locked and no bin in room. All of the residents’ rooms are spacious and bright and recent redecoration of some was clearly evident. The lack of maintenance evidenced by the number of extractor fans not working, toilet roll holders’ broken/missing, missing or blocked soap dispensers and other detailed items is not conducive to a safe environment. The inspector was informed that some of the listed items are being addressed e.g. new mixer head on order for the shower room. Wheelchairs were seen in use without the footrests or lap belts in-situ, and many of the wheelchairs seen needed cleaning. Communal areas are spacious and bright but attention to the communal carpeted areas is required either by replacement flooring or deep cleaning of existing carpets where appropriate. Specialised equipment required to assist residents to maximise their independence is clearly evident throughout the home. Many of the residents have personalised their rooms with their own pictures, furniture, entertainment equipment and other items a process facilitated by the generous size of the rooms. Cleanliness and infection control is compromised by a lack of attention to the required standards of cleaning and needs to be addressed urgently. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 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 There are sufficient staff employed to meet the assessed needs of the residents but recruitment policies are not yet robust enough to ensure the protection and safety of residents. Staff training at present falls short of that needed to provide the competency necessary to ensure the safety of all residents. EVIDENCE: The residential unit is staffed in the day by a senior carer or Residential Care Manager and at least four care staff; the nursing unit is staffed by a registered nurse and four care staff. The units are not yet completely separated, as some people receiving personal care have rooms in the nursing wing. The home also employs catering staff, a part-time administrator, an activities organiser, domestic staff and a handyperson. At night there is always an RGN on waking night duty, plus care staff. A number of staff members have left since the last inspection, with some new staff being employed via an overseas recruitment agency. A separate recent inspection revealed that recruitment records were incomplete for some new staff but action is now being taken to complete all of the necessary checks. The administrative officer has begun to compile new, comprehensive, wellorganised files for all staff. Two CRB checks were still outstanding and these must be pursued as a matter of priority. Checks on staff recruited in the last few weeks were satisfactory but a record of the interviews should be retained. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 17 Staff may not be employed under any circumstances if they do not have clearance against the POVA (protection of Vulnerable Adults) register. Induction training and supervision has been interrupted due to the abrupt departure of the manager and it is important that these are re-introduced. The Residential Care Manager, said that she is working on a revised induction procedure. Only three of the care assistants have NVQ2, so the home will remain well short of the standard of 50 of care staff with this qualification by the end of the year. Some overseas staff may hold qualifications which are comparable to NVQ2 or above but this can only be demonstrated by obtaining advice on their qualification from the relevant government agency, NARIC, and passing this to the Commission. In any event the Registered Person should seek to extend the NVQ training programme; at present only four staff are studying for NVQ. This would be helped by a period of greater staffing stability. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 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, 32, 33, 35, 36, 37, 38 The current lack of a registered manager has resulted in minimal leadership, guidance and direction to staff that ensures residents receive consistency of care and are safe in the home. Woolton Manor does not have a comprehensive quality assurance process; this results in some practices that do not promote the health, safety and welfare of the people using the service. EVIDENCE: The home’s manager was dismissed with immediate effect in early November and since then the home has been managed by the Deputy Manager (a registered nurse) and the Residential Care Manager, who has an NVQ Care 2 & 3, NVQ Level 4 - Registered Manager (Adults) and Operational Management Level 5. The Registered Person has advertised for a replacement and said that he intends to make an appointment as soon as possible. Given the size and Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 19 complexity of Woolton Manor it is essential that a new manager is appointed and registered as soon as possible. There has been no progress on the development of a quality assurance system since the last inspection and this will be a priority for the new manager when he or she is appointed. The home only deals with the personal allowance of one resident, the remainder being dealt with by families. The previous manager had begun a programme of staff supervision but this has also been brought to a halt by the change in management and needs to be restarted as soon as possible. Records are safely and securely stored in the two offices in the home. The home has full time administrative staff who ensure that records are kept up to date and accessible. Fire safety checks are carried out regularly and recorded, and staff have all received fire safety training. The home’s gas safety certificate was out of date and a new one must be obtained as a matter of urgency. The Registered Person assured the inspectors that this would be done within a few days of the inspection. The kitchen was clean and well organised. Fridge and freezer temperatures are recorded three times a day, but a few minor items of dry stores were just beyond their sell by date. Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 X 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 1 3 2 Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement The registered person must ensure that all care plans and related documents pertaining to the care of service users are relevant and up to date at all times. The registered person must ensure that all identified actual and potential problems of each service user are clearly documented, relevant and up to date at all times. The registered person must ensure that all medications are managed in accordance with the Medicines Act 1968 and The Royal Pharmaceutical Society guidelines for administration and control of medicines in care homes. The registered person is required to keep the care home well maintained and in good order at all times. The registered person must ensure that the badly burnt carpet in the residential lounge is replaced. The registered person must ensure that the home is kept DS0000025172.V272418.R01.S.doc Timescale for action 1 OP7 13 & 15 31/01/06 2 OP8 15 31/01/06 3 OP9 13 31/12/05 4 OP19 23 31/01/06 5 6 OP19 OP26 23 13(3) 31/01/06 31/01/06 Woolton Manor Version 5.0 Page 22 8 OP28 18 9 OP29 12, 19 10 OP30 12,18 11 OP31 9 12 OP33 24 13 OP36 18 14 OP38 13(4) 15 OP38 13 and 23 (4) clean, hygienic and free from odours and that clinical waste is disposed of correctly. The registered person must ensure that the NVQ training programme is extended to include all staff at the home and appropriately facilitated The registered person must obtain all the documents and records for all persons employed as specified in Schedule 2 of Regulation 19 of the The Care Homes Regulations 2001. The registered must ensure that all staff receive relevant induction, foundation and specialist training appropriate to the work they are to perform. The registered person must ensure that an appropriately experienced and qualified manager is appointed and registered with the CSCI. The registered person must ensure that an effective quality assurance and quality monitoring systems are put in place. The registered person must ensure that appropriate policies and procedures for staff supervision are in place and put into practice. The registered person must arrange for a Gas safety check to be carried out and forward a copy of the relevant certificate to the CSCI. The registered person must ensure that all risks to the service user are identified and eliminated; e.g fire doors propped open without the use of an approved hold-open device; kitchen supplies past their sell by dates. 31/03/06 31/01/06 31/03/06 31/03/06 31/03/06 31/03/06 31/01/06 31/01/06 Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 23 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 OP12 Good Practice Recommendations It is recommended that participation in social and recreational activities be included on the individual diary sheets in order to give a comprehensive picture of how a resident spends their day. 1 Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Woolton Manor DS0000025172.V272418.R01.S.doc Version 5.0 Page 25 - 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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