Care Home: Woodlands Nursing Home

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What the care home does well The acting manager has put in place clear systems to make sure that staff know what they are doing and as result the people living at the home are receiving high standards of care in a way which protects their privacy and dignity. Staff now recognise the rights and individuality of the people living at the home. The staff team work closely to improve and maintain standards of care. What has improved since the last inspection? What the care home could do better: The acting manager recognises that there is still work to be done to build on the improvements already made to ensure even better outcomes for people living at the home. The acting manager may wish to consider ways to increase the involvement of care staff on a daily basis, in the social care of the people living at the home. No requirements or recommendations have been made as a result of this inspection. CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Sands Lane Mirfield West Yorkshire WF14 8HJ Lead Inspector Gillian Walsh Key Unannounced Inspection 8th October 2008 09:45 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 Woodlands Nursing Home DS0000001100.V372695.R02.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. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Sands Lane Mirfield West Yorkshire WF14 8HJ 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) 01924 491570 01924 497377 Woodlands.Mirfield@Craegmoor.co.uk www.craegmoor.co.uk Speciality Care (REIT Homes) Ltd Manager post vacant Care Home 87 Category(ies) of Dementia - over 65 years of age (87), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (87) Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide accommodation and care for 5 named service users under 65 years of age. 31st March 2008 Date of last inspection Brief Description of the Service: Woodlands Nursing Home is owned by Speciality Care (REIT Homes) Limited which is a wholly owned subsidiary of Craegmoor Healthcare. The home provides nursing and personal care and accommodation for up to 87 older people who suffer from dementia type illnesses and mental disorders. Woodlands is a large, brick built home set within 47 acres of woodland. The home is divided into 4 units over two floors. Access to the first floor is gained via a passenger lift. The home provides single and double room accommodation. Some rooms have en-suite facilities. The home is in a secluded position, one mile from public transport but has a minibus available. Woodlands has its own gardens that includes patio areas, seating, an orchard and a pond. Some outside areas are securely fenced to allow freedom to walk or sit in a protected setting. The provider informed the Commission for Social Care Inspection on 08/10/08 that fees range from £344.56 to £767.18 per week. Additional charges include hairdressing, private chiropody, newspapers, personal choice toiletries, tobacco and clothing. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. The last key inspection at this home took place at the end of March/beginning of April 2008. At that time the Commission for Social Care Inspection (CSCI) were taking enforcement action against the company that owns the home and therefore the home was not awarded a quality rating. Enforcement action was being taken as a result of several years of fluctuating but generally poor standards within the home. Since that key inspection there have been two random inspections made at the home by the CSCI. These were made on 18 June 2008 and 29 July 2008. During these visits it was apparent that huge improvements in the standard of care and in the environment were taking place and that people were now being safely cared for at the home. As a result of these improvements the CSCI made the decision not to continue with the enforcement process. CSCI will, however continue to monitor the home closely to make sure that standards do not begin to drop. This key inspection is the first visit as part of this monitoring process and as a result of this a quality rating has been awarded (see below). As part of this inspection, all information from the random inspection, information from other people involved with the home and any other information the CSCI has gained about the home were considered. The inspection visit was made on one day by two regulation inspectors and a pharmacist inspector. During this visit we spoke with some of the people who live at the home, nursing and care staff. We examined some people’s care records, audited a sample of medications, reviewed staff recruitment records, and looked around the home. The acting manager at the home had completed an annual quality assurance assessment that was requested by CSCI earlier in the year, which includes information about people who live at the home, the staff that work there, the service provided and any incidents or accidents that have occurred. The information contained within this document was also considered as part of this inspection. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 6 Surveys were sent out by the CSCI to gain the views of people involved with the home but at the time of writing this report none of the surveys had been returned. This inspection very positive and the inspectors would like to thank all of the people involved. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: What has improved since the last inspection? Vast improvements have been made in all areas of the service. People living at the home now can enjoy: • • • • • Pleasant and safe environment due to complete refurbishment of the whole home. Good personal care due to staff training, support and good leadership. Good healthcare provision as a result of staff from the home making appropriate and timely referrals. Choices of good quality food and drinks with individual dietary needs catered for. Support to take part in activities, outings and religious services as a result of the appointments of dedicated activities personnel. DS0000001100.V372695.R02.S.doc Version 5.2 Page 7 Woodlands Nursing Home All of the above improvements have contributed to people at the home having a much-improved quality of life. 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. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is Good. People will only be admitted to the home after a thorough assessment has been completed and confirmation given that the home is able to meet their needs. Standard 6 is not applicable, as the service does not provide intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager said that although the local authority have now lifted restrictions on admitting people to the home, there have not been any new people admitted since the last key inspection. The acting manager explained that until the home is settled following the renovations and refurbishments currently taking place she does not feel it Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 10 would be wise to take new people. She also said that new admissions would then be taken slowly to make sure that staff have the time to make proper assessments of any new people and to give them the support and reassurance they may need. The acting manager also said that that either herself or one of the clinical managers would undertake a full pre admission assessment of any person enquiring about moving into the home. This to make sure that people are only admitted if the staff team are confident that they have the skills to meet the persons needs and that the environment is right for them. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 11 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. People’s health and personal care needs are met in a way, which respects their privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit care plan files from each of the three units currently in operation were looked at. All of the care plan files contained up to date information about the individual concerned. This included a range of assessments including risk, moving and handling, skin integrity and dietary assessments. Wherever an assessment had highlighted a specific need, a care plan had been developed to inform staff what care and support they should give to the individual to make sure that their needs were met. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 12 The care plans were detailed and clear and regular reviews were made to make sure that the care prescribed within the plan was being effective. Information contained within the assessments, care plans, evaluations and daily notes was consistent and tied together to give a clear picture of how the staff are supporting people in order to meet their needs. Also within the care plan is a record of visits or other interventions from healthcare professionals such as GP (General Practitioner), dentist or specialist nurse. Again the documentation within this record ties in with the care plan and the daily notes to show that staff are working other healthcare professionals to make sure that people living at the home have their healthcare needs met appropriately. On all of the units people looked clean and smart and it was evident that staff take the time to support people with their personal hygiene and appearance. Many of the people living at the home have been supported to choose and buy new clothes, ladies were wearing jewellery and had their hair styled and gentlemen (where they chose) were clean-shaven and smart. Care plans include instruction for staff as to how people like to look after their appearance, for example one care plan said how the person likes to wear a hair slide and another said that the person should be assisted to apply their lipstick as this makes them feel good about themselves. Examples such as these demonstrate that staff consider and take action to meet with people’s dignity needs. A CSCI pharmacist inspector again attended on this visit and conducted an audit of the systems in place for managing medications at the home. The pharmacist inspector found evidence of continual good practice. There are good systems in place for the accurate administration, recording and storage of medicines. This means people are receiving their medication safely and as prescribed. The current month’s Medication Administration Records (MAR) were looked at. The recording of medicine administration is good. Accurate records of administration are made and there were no gaps on the charts indicating medicines are given as intended. A record is made of all medication supplied and the date received. The quantity of medication from one monthly cycle to another is recorded on the new MAR. This means there is a complete record of medication within the home and helps when checking if medication is being administered correctly. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 13 Handwritten entries on the MAR were well written. It is important to have accurate entries to make sure people get their medication correctly. An audit of current stock and records showed that medication is being administered as prescribed. It is important that medication is given as prescribed to make sure a person’s medical condition is treated correctly. Good, detailed records are made on the chart to inform staff of dose changes to medication. This makes sure that people are getting their medication as prescribed. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 14 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 Good. People enjoy a lifestyle which meets with their individual needs and choices. Food and catering services are of a high standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last key inspection there have been huge improvements in this outcome area for the people who live at the home. The acting manager said that two activities organisers now work to cover all but two days out of each month. The activities organiser on duty showed the inspectors an example of the weekly activities programme and photographs of recent events and outings that have taken place. These included kite flying and baking sessions and a trip to see the Blackpool illuminations. One person had also been taken on a one to one trip to Scarborough. People involved in these trips said how much they had enjoyed them. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 15 Weekly activities include a coffee morning, music and films, reminiscence sessions using memory boxes from a local museum and games. The activities organiser also said that she takes people, who wish to go, to church on a weekly basis but members of the local clergy also come to the home weekly to enable those who wish, to receive Communion. A Christmas Eve service has already been planned to take place at the home. In addition to the activities organisers, care staff are starting to try to engage people in activities on an informal basis. Some staff were seen looking at newspapers or magazines with individuals. More of these types of interventions would be a great support to the commendable efforts of the activities organisers in making even further improvements to the quality of lives for people living at the home. Visitors are welcomed to the home and the activities organise said they are always looking to find ways of involving the home more in the local community. A very successful garden party during the summer months had been well attended by people from the local area. New menu’s were seen to be in place and all of the people spoken with, who were able to comment were complimentary of the food they received. The chef has taken action to make sure that the one person currently in need, has a diet in accordance with their religious needs. The catering department in the home has recently been awarded five stars by the local environmental health office for it’s high standards. There has also been a huge effort to make sure that people who need it, receive fortified meals and extra snacks. Milk shake made with cream and fruit is served and people were seen to be given extra snacks during the day. The menu has also been reviewed to provide people with more choice and a more substantial diet. People were seen to be offered choice of where they ate and to be supported with their meals and drinks. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 16 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. People can be confident that their complaints will be taken seriously and that systems are in place to protect people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager said that the home has not received any complaints since the last key inspection. She also said that relatives meetings are now held much less frequently, at the request of relatives, due to people being much more satisfied with the service provided at the home. Since the last inspection, no complaints about the home have been received by the Commission for Social Care Inspection Records showed that all staff have now had training in safeguarding people. No safeguarding referrals have been made relating to the home since the last inspection. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 17 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 and 26. Quality in this outcome area is Good. People live in a clean, comfortable and pleasant environment which is being maintained to a high standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is nearing the end of a very substantial refurbishment programme. New windows have been fitted throughout and internal refurbishment is now complete in two of the four units. The acting manager said that the whole project should be complete by early next year. The refurbishment has been done to a very high level and includes new lighting, new fire alarm system, new furniture, new flooring, new beds and new soft furnishings. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 18 People are being supported to personalise their rooms and several people have been supported in buying wide screen televisions with DVD players for their rooms. Areas of the home not yet refurbished were clean and tidy. A member of the domestic staff said that it is now a pleasure to clean and look after the home. The outside of the home has also undergone improvement. The addition of plants and conifers and pebbled areas near the main entrance give the home a much more attractive appearance. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 19 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 Good. People are supported by an appropriately recruited, well-trained staff group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although there have been some changes to the staff team since the last inspection, the acting manager has continued to recruit appropriately trained and experienced staff to support the continued improvements in care processes at the home. All of the units are staffed in appropriate numbers to meet the needs of the people living there and records show that all staff now follow a well-planned training programme. All new staff undergo a three-day period of induction training, which is supported by further induction at the home which continues for a period of up to six months. The induction covers mandatory training such as moving and handling and safeguarding people as well as working with staff to get to know the needs of the people living at the home and the care processes. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 20 Four staff files were checked during the visit and all contained the required documentation to show that proper checks had been taken during the recruitment stage to make sure that people living at the home are protected. The acting manager said that she trying to reduce the agency use through continued recruitment of permanent staff. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 21 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 Good systems of management and administration make sure that the home is run to a high standard in the interests of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager has been in post for approximately twelve months. In this time she has taken a pivotal role in the enormous improvement in all areas of service at the home. Her dedication to the improvement of quality of life for people living at the home has earned her the respect of all involved including the staff who have recently nominated her for an award within the company. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 22 As part of her duties the acting manager has organised the refurbishment of the home with minimal disturbance to the people living there whilst at the same time, with the support of clinical managers and the staff team, has hugely increased the standard of care given to people living at the home. To maintain these standards, a daily system of quality checks is in place. The acting manager said that she is preparing to apply to the Commission for Social Care Inspection for registration as the manager of the home. The acting manager said that no money is held within the home for people who live there. A system is in place whereby money can be requested by anybody living at the home at any time and this will be obtained from the petty cash held. This money will then be withdrawn from the person’s own bank account, which the home has set up for them, and paid back into the petty cash. Records of all transactions are electronically held. Receipts for all withdrawals and purchases are retained. Records of transactions were seen during the visit and found to be well maintained and appropriate. Daily checks are made of systems within the home to make sure that the health and welfare of people living and working at the home is protected. Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 23 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 X 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 3 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 3 X 3 X 3 X X 3 Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 24 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 Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Woodlands Nursing Home DS0000001100.V372695.R02.S.doc Version 5.2 Page 26 - 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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