Inspection on 06/05/05 for Woolton Manor

This inspection was carried out on 6th May 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 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 06/12/05

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 L25 7TB Lead Inspector Miss Julie E King Mr Peter Creswell Unannounced 06 May 2005 9:30 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. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woolton Manor Address Allerton Road Woolton Liverpool L25 7TB 0151 421 0801 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) Mr Abid Yousaf Chudary CRH 70 Category(ies) of OP registration, with number 70 places of places Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 42 Nursing and 35 Personal Care within an overall total of 70 One (1) named male service user under 65 years of age (N) within 42 (N) OP and 35 (PC)OP within an overall total of 70 Date of last inspection 27 October 2004 Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 5 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 F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection took place over five hours and was conducted by two inspectors. A full tour of the premises took place and through examination of records such as care plans, staff personnel files and policies and procedures were also examined. A number of staff, and many residents were spoken to during the course of this inspection by both inspectors. What the service does well: What has improved since the last inspection? What they could do better: Management of medications on the nursing unit need to be managed better, in accordance with current good practice requirements and recommendations. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 7 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 F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 8 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 Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 9 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 & 4 Residents are only admitted into the home on the basis of a full assessment is carried out prior to they move in. This helps ensure that the staff can provide the appropriate package of care for all residents. EVIDENCE: Since the previous inspection last year, the standard and detail of the Statement of Purpose, Service User Guide and pre-admission assessments has greatly improved. All pre-admission assessments are carried out by either the residential manager or home manager, depending whether the prospective resident is needing personal or nursing care. Multidisciplinary healthcare team members such as the resident’s social worker, physiotherapist or NHS ward nurse, plus members of their family as wanted, are part of this process. Specialist healthcare professionals continue to be involved in the care of residents after they are admitted into Woolton Manor. All the residents spoken to during this unannounced inspection told the inspectors that they “felt my needs are met”. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 10 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 & 10 The care plans seen were able to show how the resident’s care needs are met. Medication management was an area that the nursing wing of the care home needs to improve on. EVIDENCE: Individual care plans had been documented for each resident, and all seen had been updated and reviewed recently, with the involvement of the individual resident as far as possible. Big improvements were seen in the overall standard of the care plans, both in the detail and in the way they are recorded on a daily basis. Systems are in place to ensure good communication between the care home, the NHS and other professionals involved in the care of all the residents. All this contributes to the safety and well-being of the residents. It was evident that all the resident’s needs are currently being met through examination of the care planning process. Systems are in place for the management of medications, but the nursing unit did have some room for improvement regarding stock control, medication / GP reviews and recording. The residential unit evidenced good practice with all medications seen. The residents spoken to during the inspection all commented on the high standard of care they received. They confirmed they Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 11 had access to various healthcare professionals as necessary, and stated that the care staff always respected their privacy and dignity. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 12 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. The daily routines provided were flexible and residents could exercise choice and control over their lives. Friends and family are actively encouraged to participate in the resident’s lives. A varied and nutritious diet was provided with resident’s medical needs being catered for. EVIDENCE: Woolton Manor now employs a full time Activities Organiser. She has arranged an extensive programme, including some one to one activities such as manicures (for men as well as women) which residents particularly enjoy. The activities co-ordinator consults with residents and tries to arrange the kind of activities which they say they want. She has arranged a garden fete in the near future and residents have played their part in organising this. Several residents were growing seeds in their rooms as part of the gardening programme. Plans for the summer include short trips out for small groups of residents. Activities are not recorded in detail on individual resident’s files. If this was recorded it would help both to provide evidence of activities participated in, and demonstrate the planning of any future activities. Residents said that the enjoyed the meals at Woolton Manor. Cooked breakfast is available every day and choices are available at other meals on request, though they are not set out on the menu. The record of food served Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 13 showed where alternatives had been prepared. The main meal is usually served in the evening/late afternoon with a lighter, though often cooked, meal at lunchtime. Meals are freshly prepared – the soup served on the day of the inspection for instance, was home made. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 14 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) 16, 17 & 18 An efficient complaint and adult protection policy and procedure was in place to help ensure the safety and welfare of residents. EVIDENCE: Woolton Manor has a detailed complaints procedure that staff can access when necessary. This procedure includes information on ‘whistle-blowing’, in accordance with the Department of Health ‘No Secrets’ guidelines. The CSCI has received two anonymous complaints about this service since the previous inspection last October. Most of the staff have now completed training in adult protection, with the remaining having training planned for the near future. However all staff do receive basic training in the protection of vulnerable adults during induction. The residents all spoke highly of the staff team and said they “have no complaints about how I’m treated”, and “nothing is too much trouble”. Some advocacy information was available if required by residents. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 15 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, 23, 24, 25 & 26. The overall fabric of the building is of a good standard, with most resident’s rooms being highly personalized. However the ongoing programme of redecoration and refurbishment must address the issues identified during this inspection. EVIDENCE: All of the residents of Woolton Manor have individual bedrooms and all but one have en suite facilities. A number of the bedrooms also have en suite showers or baths. As well as this there are sufficient bathing and toilet facilities throughout the building. The bathrooms are bright and well decorated but the support frame in the toilet near to room 19 is badly rusted and must be repainted or replaced. The bedrooms are spacious and well decorated. The family of one resident has provided additional kitchen facilities in the bedroom, including a microwave oven, turning it into a self contained bed sitting room. The bedrooms are spacious and well decorated and all of the residents who spoke to the inspector were happy with their room. The door in room 35 Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 16 needs to be repainted. Two vacant rooms have vinyl flooring but if a new resident moves in they would be given the option of having a carpet fitted. Some of the carpets may need to be replaced in the near future and two of them were badly stained and must be replaced if they cannot be adequately cleaned (rooms 5 and 47). There were malodours in two rooms and this was pointed out to the Registered Manager on the day of the inspection. Sanitary supplies were stored inappropriately and untidily in room 61. There was a stair gate fitted to one bedroom doorway (for the safety of the resident) but no risk assessment was on file. Some of the original bedroom door locks have been replaced by latches which do not enable the resident to lock the room. One of these (Room 10) is broken and must be replaced, preferably by a lock that can be opened from the outside in an emergency and can be opened from the inside in a single movement. The two large lounges are spacious and well decorated, as is the dining room and the dining area adjoining the main lounge. Some residents choose to have meals in their own rooms, especially at breakfast time. The wide, carpeted corridors are being redecorated as the beginning of a major general redecoration programme. Immediate attention needs to be given to a cracked window and the stained ceiling in the ground floor corridor of the northern (Mother Teresa) wing. The kitchen was clean and well organised. The kitchen was clean and well organised, with fridge and freezer temperatures checked and recorded daily. A number of dry stores (mainly sauces and seasonings) were out of date (in one case by three years). Dry stores must be rotated and checked regularly to ensure that ‘use by’ dates have not expired. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 17 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) 27, 28, 29 & 30. After a period of considerable instability in staffing there is now a good number of permanent staff offering consistency of care within the home. However not all checks have been completed on new starters which does not ensure the safeguarding of all residents. EVIDENCE: The home is adequately staffed, with a qualified nurse and four or five care staff on duty in the daytime. Not all recently employed staff had the appropriate checks completed and this must be addressed as a matter of urgency. The staff rota evidenced a much lower use of agency than in previous inspections, with only three shift having agency the week of this inspection. Staff spoken to during the inspection confirmed that a range of mandatory and specialist training was now available, with the majority of the cost being paid for by the care home. This approach to training is a positive aspect of Woolton Manor, as it helps ensure that residents are being cared for properly and their needs are being met in accordance with current good practice guidelines. Recruitment and selection policies and procedures were in place, but a number of staff personnel files lacked all the required documents and records, especially regarding relevant CRB and POVA checks. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 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 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, 32, 33, 35 36, 38. The new manager has a clear development plan and vision for the home, which she has effectively communicated to staff and residents. The current system of managing resident’s personal allowances is not compliant with the national minimum standards. EVIDENCE: The new manager is highly experienced and well qualified for the post. She has set up a programme for individual staff supervision and is personally appraising all staff before putting that programme in to action. She is also putting in place a quality assurance system based on written feedback from residents and their families. Fire safety records were up to date but a number of bedroom doors were wedged open. These are fire doors and must not be wedged open as this makes them ineffective. Products are available which hold the door open but Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 19 close if an alarm is sounded and must be fitted if the doors are to be kept open. Residents accounts that are held by the care home were examined. The accounts were individual as required, but are managed via a bank account held in the home’s name. This practice must cease immediately, and the accounts held for any resident must be individualized to each resident for all transfers. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 2 x 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x 2 2 x 2 Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 21 yes 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 9 Regulation 13 (2) Requirement The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person must put right the following- gaps on the medication administration records; overstocking, lack of temperature recording, out of date medications, no Oxygen signage, lack of reviews involving GP. The registered person must ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally at all times - and must address the following rusty toilet frames, worn or stained carpets (rooms 5 & 47); broken lock on room 10; and cracked window ground floor corridor. The registered person must keep the care home free from offensive odours at all times. The registered person must obtain all the documents and Timescale for action 30 May 2005 2. 19 and 21 23 (2) 15 June 2005 3. 4. 26 29 16 (2) 19 30 May 2005 15 June 2005 Page 22 Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 5. 35 20 6. 38 13 and 23 (4) records for all persons employed as specified in Schedule 2 of The Care Homes Regulations 2001. The registered person must not pay any money belonging to any service user (resident) into a bank account unless the account is in the name of the service user. The registered person must ensure that all risks to the service user are identified and eliminated. In order to do this fire doors must not be propped open unless fitted with an approved hold-open device; risk assessments must be completed for the resident who has a safety gate in her doorway; kitchen supplies must be regularly checked to ensure that they are not past their sell by dates. 30 May 2005 30 May 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 3 7 7 9 7 Good Practice Recommendations It is recommended that the pre-admission assessments incorporate more detail regarding oral and foot health of prospective residents. It is strongly recommended that all entries in residents daily records are signed, dated in full, and the 24hour clock is used to identify the time of the entry. It is strongly recommended that no abbreviations are used on any resident record. It is recommended that the medication room temperature is recorded on a daily basis in accordance with current good practice guidelines. It is strongly recommended that more specific details are included on specialist care plans, such as wound care, etc. Woolton Manor F52_F02_S25172_WooltonManor_V223950_060505_Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Liverpool Area Office 3rd Floor 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. 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