Care Home: Woodside

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What the care home does well Overall, residents consistently expressed a high level of satisfaction with respect to the quality of care and support they received, a view shared by both visiting relatives. However, they have raised a few issues for improvement. The comments from residents, relatives and staff have been reflected throughout the report. The assessment and admission process is good, thus ensuring that the residents` needs could be met on admission to the home. The implementation of health and personal care needs are being monitored internally through a monthly review system, which involves the resident and their family. Woodside benefits from having a well-established core staff team, which means the home does not have to depend on agency staff; this has ensured consistency and continuity in the overall quality of service delivery. The complaints policy is easily accessible to residents, relatives and significant others. As well as being summarised in the service user`s guide, it is also on display in the entrance hall of the home. There are a number of systems in operation, which should offer adequate protection to residents. What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE Woodside The Old Vicarage Slip End Nr Luton Bedfordshire LU1 4BJ Lead Inspector Neil Fernando Unannounced Inspection 8th April 2008 10:00 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 Woodside DS0000014988.V362114.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. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodside Address The Old Vicarage Slip End Nr Luton Bedfordshire LU1 4BJ 01582 423646 01582 423646 vibhakiran@aol.com 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) Shires Healthcare (Woodside) Limited vacant post Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (28) Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th April 2007 Brief Description of the Service: Woodside is a residential care home that accommodates up to twenty-eight older people who may also have physical disabilities and/or dementia. The registered providers are Shires Healthcare (Woodside) Ltd. The home is located in a rural area at the edge of the village of Slip End. Single room accommodation is provided. The premises have been suitably adapted to meet the service users assessed needs with the exception of access to en-suite toilet facilities, which is limited in most instances and suitable only for those without mobility problems. Twenty-one of the bedrooms have en-suite toilet facilities. Both a passenger and stair lift is available to access the second floor. The third floor is used as a laundry, storage area and for staff accommodation. There is a modest size well-maintained garden, with shrubs and mature trees. Residents spoken to said that the garden is well used during the warmer season. Access to the M1 and Luton town is nearby. A copy of the service user’s guide and inspection report is available for residents and visitors to read. The fees for this service vary between £450.00 and £495.00 per week. Woodside DS0000014988.V362114.R01.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 stars. This means the people who use this service experience good quality outcomes. We, the Commission for Social Care Inspection, undertook this unannounced key inspection on 8 April 2008. We spoke with 6 residents, 2 visiting relatives, the responsible person and the new manager, and 3 members of staff. We had a look round the accommodation and viewed a range of records the home must keep, and observed staff care practices. At the time of the visit, there were 20 residents accommodated with eight vacancies. We received a completed “AQAA” (Annual Quality Assurance Assessment) – a document, which gives the manager the opportunity to tell us how the agency is meeting the standards and regulations. To date, we have received surveys from 4 staff and 1 service user. Any information received would be included in the next inspection report, as necessary. The responsible person and manager were present throughout the inspection. What the service does well: What has improved since the last inspection? Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 6 The service user’s guide and statement of purpose have been reviewed and updated. Suitable arrangements are in place to ensure that all staff understands the importance of respect and dignity towards residents. Personal care was seen being given in a sensitive and respectful manner. Staff members have made a concerted effort to offer an improved level of social and recreational activities for residents. New menus are being introduced in consultation with residents; picture menus are now also available to ensure residents with cognitive impairment are able to make choices at mealtimes. Evidence shows that suitable and wholesome, nutritious meals are provided for residents. Accidents/incidents and significant events in the home are appropriately recorded and reported to the Commission. The new manager is confident and determined to maintain good standards and in the way it operates. In this, she is well supported by her line manager – the responsible person. 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. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3, 4 and 5. Standard 6 is not applicable to this home. Quality in this outcome area is good. Anyone considering Woodside as a home, either for themselves or for someone else, are given the necessary information and opportunity to visit the home, so that they can make an informed decision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and a service user’s guide, which have recently been reviewed and updated. A copy of the most recent inspection report is available to residents and visitors. Each resident is issued a contract when they move into the home; although basic, it does state the terms and conditions of their stay at the home. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 9 Case records for three residents were examined and they all contained good pre-admission assessments completed by the manager or deputy manager, prior to an offer of a placement being made. They provide a detailed profile of the residents’ needs and the level of assistance required. These assessments all contained information relating to health matters including pressure care, mobility, nutrition, social and recreational activities, culture and religion and personal capabilities and preferences. These assessments are all clearly dated and signed by the manager or the deputy manager. Information about the prospective resident is also sought from their family, health and social care professionals. The prospective resident and their family are encouraged to visit the home and meet with staff and have a meal with the other residents. Residents have a care plan prepared for them, which is based on the assessment of needs. There is a wide range of specialist services available to the home via GP referral and other appropriate channels. Examples include district nurses and occupational therapists. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. The residents observed during the course of the visit appeared to be well cared for and they were being treated with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for three residents were checked. The information they contained was detailed and up to date. Residents’ needs including health, personal hygiene, dressing, mobility, communication, food and religion were clearly identified and being addressed. The residents, where appropriate and their representatives should sign the care plans; this wood show that they have contributed and are in agreement with the contents. Staff members spoken with demonstrated a good understanding of equality and diversity issues relating to residents they are key workers for, in particular. Care plans Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 11 include evidence of the involvement of health care professionals. Staff members review care plans monthly. Risk assessments are completed and updated as and when required. The policy and procedure on medication is available and accessible to staff members. Only senior care staff are authorised to administer medication. The medication trolley was tidy and well organised. There was a specimen signature sheet at the front of the records file, and each individual sheet had a photograph attached so that residents could be easily identified. Any controlled medication is stored in a locked steel cabinet and a “Controlled Drugs Register” is kept for this purpose. A staff member was seen administering medication soon after lunch and this task was carried out satisfactorily. The medication administration records were examined for eight residents and these were in order. Residents spoken with said that they receive their medication on time. Privacy and dignity is a subject included in the induction programme for all staff members. Personal care was seen being given in an appropriate and respectful manner; the feedback received from residents about the standard of their care is very positive. “The carers are very good” is a typical comment made by residents. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 and 15. Quality in this outcome area is good. Residents have opportunities to participate in activities that are appropriate to their needs. Residents can be assured that they will be offered a varied diet that meets their requirement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are being encouraged to follow the lifestyle of their choice as discussed and agreed during their assessments. All of the four care plans examined reflect the residents’ identified needs, and in the main, these are being addressed. Residents spoken to generally expressed satisfaction in this area. However, two residents felt that the level of social activities could be improved. The responsible person and the manager said that arrangements were in hand to recruit an activities co-ordinator in the near future. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 13 Residents said that relatives and friends are able to visit them at any time and they are always made welcome. Both visiting relatives confirmed that visiting times are flexible and staff members are always welcoming. Policy and procedure regarding equality and diversity is available and this is being updated to include human rights. All of the current residents are White UK, bar three people who are from a minority ethnic group; their cultural and religious needs are being catered for. A priest from the local church visits the home fortnightly and offers services. Staff said that all residents enjoy participating in religious services. New menu is being introduced in consultation with the residents. We observed staff supporting those residents who needed assistance at mealtimes. They were patient and gentle in their approach and mealtime was unhurried. Three residents said that alternative meals are provided if they do not like the meals on the menu. Snacks and beverages are readily available. Residents reported that “food is very good” bar one that said, “It could be better”. A relative, who was present in the dining room at the time, said, “My mum was in quite a poorly state when placing her here but she has improved greatly with the food”. Both relatives spoken with are very satisfied with the quality of care offered to their relatives at Woodside. “As a technical operator in an occupational therapy department, I have visited quite a few homes but this is the best”, said one relative. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. Policies and procedures are in place to safeguard residents from abuse. Residents and relatives are confident that their complaints will be listened to and investigated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The procedure on complaints is available to all staff. Information on how to make a complaint is included in the statement of purpose and the service user’s guide. Some of the residents spoken with said that they are aware of how to make a complaint and any concerns raised with staff, will be dealt with to their satisfaction. The complaints record examined indicates that the home has received 3 complaints since the last inspection in April 2007. Evidence shows that these complaints have been resolved satisfactorily. There has been no complaint reported to the Commission, since the previous inspection in April 2007. The home has a copy of the procedure on adult protection. Staff members interviewed showed an understanding of the above procedure. All members of Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 15 staff have received training on adult protection. This is a subject also included in the induction programme for all new staff members and those people undertaking the NVQ assessment. There has been one adult protection matter, which was dealt by the local adult protection team. There are a number of systems in place, which should adequately protect a resident from harm. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 16 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): Standards 19, 20, 23 and 26 Quality in this outcome area is good. The environment is safe and residents live in a comfortable surrounding. A good standard of cleanliness was evident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Health and safety policies and procedures are in place, and the new manager is updating these as necessary. Records examined, evidence that residents and staff are offered the protection of reasonable safety measures. The Bedfordshire and Luton Fire and Rescue Service carried out a fire safety audit on 19 February 2008. In a report dated 26 February 2008, the fire officer had made a number of requirements, which must be addressed by 31 October Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 17 2008. The responsible person said that 80 to 90 of shortfalls identified have already been addressed and arrangements are in hand for the remaining work to be completed by May 2008. The communal areas and bedrooms are decorated and furnished in a style to reflect the period features of the building. Furniture and fittings are of a good standard. There are two lounges and a dining room with an extension overlooking the garden, which provide sufficient communal space for residents. Some of the residents remain in the dining area throughout the day. Eight bedrooms were viewed; these have been personalised with items of furniture and ornaments to reflect residents’ own taste. Residents said that they were happy with their bedrooms and other facilities. This is a very homely place, said two residents. In terms of improvement, the AQAA indicates “Continue with re-decoration plan. Receive quotes for new electric front gates to improve the security of the Home”. Areas that require some maintenance or repair include the following: a) Loose floorboard in the corridor near room 16. b) Some parts of the accommodation require redecoration. c) Room 16 has two doors but only one has a lock. A lock must be fitted to ensure privacy and dignity of the occupant. A good standard of cleanliness was evident throughout those areas viewed. Suitable arrangements are in place for the storage and collection of domestic and clinical waste. The garden is well maintained. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30 Quality in this outcome area is good. The numbers and skills of the staff are adequate to provide a good standard of care. Staff recruitment process is robust, which means that residents are in safe hands. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA indicates “There are no requirements for the usage of agency staff at Woodside. We have a full complement of staff and comply with the staffing levels. The home has over the 50 required staff completing or working towards an NVQ level 2/3/4”. Staff duty roster for a period of one month was scrutinised and discussion with staff members including the manager indicates that day and night staffing levels are adequate to meet the needs of the current residents. The home currently employs 4 professionally qualified nurses from overseas as senior care staff. There are 5 care staff members who have completed their NVQ level 2 and another 4 are currently working towards level 2/3 Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 19 assessment. This gives a high ratio of significantly experienced staff members on each shift. Feedback from 2 relatives is very positive; “Very good and competent staff” reported one of them. We looked at the recruitment files for 3 staff including a new member who has joined the team. The files are very well organised, making it easy to find required information. Robust recruitment practices are observed to offer protection to residents. Required documentation including CRB and PoVA checks were available, bar a current photograph. Records show that new members have received induction. A recently recruited staff said, “My induction was good and very helpful”. Other training completed by staff since the last inspection in April 2007 includes adult protection, dementia, medication and some mandatory training. Issues regarding mandatory training are dealt with under Management and Administration. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 36, 37 and 38 Quality in this outcome area is good. Residents accommodated benefit from living in a stable environment, which is well managed. Mandatory training must be provided to ensure the safety of staff and welfare of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous registered manager left in March 2008; the new manager has been in post since the end of March. She intends to apply for registration by July 2008, on completion of her probationary period. She is a professionally Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 21 qualified social worker and she hopes to start the Registered Manager’s Award at the end of April 2008. Staff and residents spoken with praised the management of the home and said they felt supported and could speak with the manager at any time. “She is brilliant”, said one staff member. Quality assurance systems are in place to seek the views of service users, relatives and significant others. Monthly visits by the responsible person to ensure appropriate standards are being maintained have been carried out; reports of the visits carried out are available at the home. Staff spoken with confirmed that formal supervision now takes place and that this happens about every eight weeks at minimum; all supervision is recorded and signed. Annual staff appraisals also take place. All records viewed were found to be in good order. The home has a comprehensive set of policies and procedures that cover all aspects of its management and care provision. Staff confirmed that regular fire tests and drills are carried out. However, records of fire drills must include the name of participants, evacuation timescales and remedial action taken, if any. Risk assessment of the physical environment is carried out as appropriate. Evidence is available to show that some of the staff interviewed had not completed their mandatory training such as first aid and food hygiene. The responsible person and the manager are aware that action is required in this area. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 22 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 X X 3 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 3 X 3 X X 3 3 2 Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 23 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. 1 Standard OP19 Regulation 23 (2) (b), (d) & (e) Requirement Areas that require some maintenance or repair including the fitting of a door lock to room 16, as identified under standard 19, must be completed. Recruitment files must include a recent photograph of the individual staff, as specified in schedule 2 of the regulations. All staff must receive the required mandatory training, in order to ensure a safe working practice. Timescale for action 08/07/08 2 OP29 19 & sche. 2 20/05/08 3 OP38 18 (1) (c) 08/07/08 4 OP38 17 (2) Records of fire drills must include 08/06/08 sche. 4 14 the name of participants, evacuation timescales and remedial action taken, if any. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The care plan should include the signature of the resident and their representative as appropriate; this would demonstrate their participation in the care planning process. Woodside DS0000014988.V362114.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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