Inspection Report on
Woodcroft Care Home Ltd
Woodcroft Care Home 216 Abergele Road Old Colwyn Colwyn Bay LL29 8AS
Date Inspection Completed
12/12/2019 Welsh Government © Crown copyright 2019. You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] You must reproduce our material accurately and not use it in a misleading context. Description of the service
Woodcroft Care Home is situated in Old Colwyn and provides care and accommodation for up to 22 people aged 65 and over, living with dementia.
The service provider is Woodcroft Care Home Limited. Andrew Snook is the responsible individual (RI) overseeing the service. The manager is registered with Social Care Wales.
Summary of our findings
1. Overall assessment
The care and support provided at Woodcroft Care Home is good. People are treated with warmth and kindness from a dedicated management and staff team, who have a good understanding of their needs, and what is important to them. The service has sound management structure in place to oversee and monitor the service to ensure that it operates safely and efficiently for the people receiving care and support.
2. Improvements
The home was recently re-registered under the new Regulation and Inspection of Social Care Wales Act 2016 (RISCA) and this was their first inspection under the new legislation. Any improvements will be considered as part of the next inspection.
3. Requirements and recommendations
Section five of this reports sets out recommendations to improve the service. These include updating the statement of purpose (SOP), personal plans and risk assessments, staff supervision, RI three monthly visits and quality care review.
Page 1
1. Well-being
Our findings
People are treated with dignity and respect. We observed staff interact with individuals in a sensitive and kind manner. Staff ensured that people and their relatives/representatives were listened to and communicated with, in a courteous manner. People’s care and support needs were the focus of staff’s attention with staff being able to use distraction techniques to de-escalate challenging situations. The people we spoke with told us they felt “safe” in the home and the relatives we spoke with praised the service. Comments included “care is person centred and dementia friendly”, “staff and management really do go the extra mile” and “it’s like no other care home I have ever been in, the staff are very welcoming. The trust is there”. The staff we spoke with were happy working at the service and described the home as an “extended family”. People have positive relationships with staff, which enhances their well-being.
The service supports people with their physical, mental and emotional well-being; however, improvements are required to ensure everyone has an initial personal plan before they begin to receive care and support. Staff had access to person centred personal plans, which provided information about people’s routines, personal preferences and care and support needs. People have opportunities to be physically and mentally engaged by staff who are well trained and feel supported in their roles. There are arrangements for ongoing cycle of quality assurance to seek the views of people receiving a service, their relatives/representatives and external professionals, on all aspects of the home. Overall, people receive the right care and support but further consistency is required to ensure staff have access to an initial personal plan before care and support is provided to new admissions.
The service protects people from poor or neglectful practices. We reviewed the latest safeguarding policy and procedure, which was aligned to current legislation, national guidance and local adult safeguarding procedures. A whistle blowing policy and procedure was available and provided information on the procedures for raising a concern, the safeguards in place for staff who raise a concern and how concerns will be investigated. Discussions with staff and training documentation evidenced staff had completed safeguarding training and had access to an annual refresher. The staff we spoke with had sound knowledge of the safeguarding and whistle blowing policy and procedures and were confident in raising any concerns with senior staff or the management team. People are safe and protected from abuse and neglect.
People live in safe and suitable accommodation. A visitor’s book was located within the front reception to ensure records were kept of all persons entering the building. We were required to present our identification card and sign in on arrival and on departure. The
Page 2 service was well maintained and benefits from an ongoing maintenance program. We saw visual aids such as signage and pictures were displayed around the home to help orientate people to minimise confusion. People live in a dementia friendly service.
Page 3 2. Care and Support
Our findings
Overall, staff have access to personal plans. We reviewed three care files and saw evidence that the service had completed enquiry forms and pre-assessment documentation prior to people moving into the home. Each file contained personal plans, which were person centred and included clear and constructive guide for staff to follow about the individual, their care and support needs and the outcomes they would like to achieve. However, it was noted that some personal plans were in need of updating and a person who was admitted to the home on the 11 November 2019 did not have fully completed personal plans. It was also noted that national risk assessments were not always in use such as falls risk assessments. This was discussed with the manager who assured us it would be addressed and that they were currently working alongside an external health professional to complete the new risk assessments. The staff we spoke with were satisfied with the volume of information available to them and we saw staff delivering care and support in line with people’s personal plans and preferred routines. We conclude people’s well-being is promoted but further consistency is needed around care documentation and risk assessments.
The service has systems in place to ensure management and staff have clear oversight of people’s health and welfare. We viewed the dining menus and saw they offered healthy meal choices, which were freshly prepared by the in-house cook. The people we spoke with and relatives/representatives praised the food that was served. Special dining events were also held such as Valentine’s Day, St Patricks Day and Dydd Gwyl Dewi Sant (St David’s Day), Easter, Mothers Day and Father’s Day. Personal plans contained specific information about individual health conditions. We saw people were assisted to access additional services from health and allied health professionals. Referrals were seen to be made in a timely manner with clear documentation kept of all correspondence to provide a clear health record for the individual. Medication administration records we viewed showed that people received their medication as prescribed from trained and competent staff. We saw effective systems were in place to ensure oversight and audit of medicines management. People are supported to access healthcare and other services to maintain their ongoing health and well-being.
People have opportunities to take part in activities. We were told by staff that people have the opportunity to engage in meaningful activities should they want to. Activities included ball games, quizzes, arts and crafts and dominos. People also completed daily living activities such as setting the tables ready for lunch, which we observed during our inspection. The service had its own minibus, which meant people living in the home could have trips out. During the warmer months, the home held a summer BBQ with live music.
Page 4 We saw photos from this event, which contained photos of people laughing and dancing with their families/representatives, staff, manager and the RI. On the second visit, a choir had visited the service, which was very personal to a person living in the home. The finishing touches were also being put in place for the home’s annual Christmas Party which was being held at the service. We conclude people are as active as they can be and have opportunities to be involved in activities.
Page 5 3. Environment
Our findings
Care and support is provided in a warm and welcoming environment. We toured the building and noted the cleanliness of the home and people had sufficient space to spend time individually and communally. The environment included features to stimulate people’s memory and senses, for example, memory boxes, and local and past decade’s pictures. The memory boxes were located outside each bedroom, which can help stimulate memories and support people with communication. A person we spoke with could identify their bedroom to us and spent time reminiscing about the photos in their memory box. We viewed 10 bedrooms all of which contained good natural light and were personalised to varying degrees. We saw the up-stairs hallway was currently being refurbished in order to maintain high standards. It was noted that the new hallway gave a sense of walking down a street rather than an ordinary hallway. The bedroom doors looked like front doors and were painted in different colours. The bathrooms within the home were clearly identified and included the same clear signage. The downstairs bathroom had been refurbished and contained a sensory ceiling to aid relaxation and calmness. The upstairs bathroom was also undergoing the same refurbishment. There was a safe and enclosed garden which was accessible to people and we were told by the manager that they were hoping to develop the garden further next year. Our observations of the environment and our discussions with the manager, staff and family/representatives confirmed that the RI continues to invest in the environment in order to keep standards high. We conclude the service benefits from on- going maintenance and development, in order to ensure people live in a high quality environment.
The service has systems in place to ensure people living in the home, the staff and visitors are kept safe. We saw each person had an up-to-date personal emergency evacuation plan (PEEP) in place; each plan contained specific information and procedure for assisting each person living in the home during the event of an emergency. The service was inspected by the fire and rescue service in July 2018 and were given a reasonable standard of fire safety. The records we reviewed evidenced there were systems in place for checking and maintaining fire safety within the home. We saw documentation, which evidenced that weekly and monthly fire checks had been carried out consistently throughout the year. Documentation and our discussion with the maintenance team confirmed that a water mist system is to be installed in 2020, which is a new fire protection system. Staff training documentation evidenced that fire safety in the workplace is completed by all staff working at the home. We conclude people live in a safe environment.
Page 6 4. Leadership and Management
Our findings
People have access to information about the service. We reviewed the statement of purpose (SOP), which contained the necessary information required, and was found to be in keeping with the care and support we observed on the day of inspection. We recommend further clarity is needed in relation to governance arrangements. We reviewed a selection of policies and procedures which were available to staff. The policies we reviewed were up-to- date and aligned to current and national guidance. People receive a service in accordance with the SOP and policies and procedures.
Measures are in place to ensure staff are trained and suitable to work with vulnerable people. However, further oversight is needed to ensure all staff have a valid disclose of barring service (DBS) certificate. We reviewed the staff training documentation and saw staff had completed mandatory and service specific training, in order to meet people’s individual needs. The staff we spoke with were happy with the quality and frequency of training and confirmed it was a mixture of face-to-face training and e-learning. We reviewed three staff files and saw that robust recruitment checks had been completed prior to staff starting work at the service. It was evident from the staff files that the necessary pre- employment checks, such as references and disclosure and DBS checks, had been completed and found to be satisfactory. We did note that not all staff had an up-to-date DBS. Under new regulation, the service provider must apply for a new DBS certificate within three years, for staff members who are not registered with the DBS up-date service. We discussed this with the manager who assured us it would be addressed. Overall, people receive a service that has a good selection and vetting system in place to ensure people’s safety and well-being. However, further consistency is needed to ensure staff DBS’s are kept up-to-date.
People receive care and support from a manager who provides a positive work ethos and culture at the service. On both days, we saw the manager interact in a sensitive, kind and supporting manner with all individuals living and working at the service. The staff we spoke with felt fully supported by the manager comments included “she’s very approachable and supportive” and “she’s always willing to help out - she wouldn’t ask us to do anything she wouldn’t be willing to do herself”. We reviewed a sample of supervision and appraisal documentation, which helped staff reflect on their practice and made sure their professional competence is maintained. This included feedback about their performance and identified areas for training and development. A staff annual appraisal and supervision matrix was not available on the day of inspection, and we did note some gaps in staff supervision, which does need to be addressed. People and their relatives/representatives can be confident that the service is led and managed to a good standard.
People receive high quality care and support from a service, which sets high standard for
Page 7 itself. We saw the service had received questionnaire feedback from people using the service and their relatives/representative, staff and external professionals. The sample we reviewed were all positive, comments included “excellent care and kindness” and “homely atmosphere”. We recommend that a report is produced which shows what actions are required to address any issues that are highlighted in the responses. We spoke to the RI during both visits and it was clear that they were very much involved with the home. This was also confirmed by the manager, staff and relatives/representatives of the people receiving a service. However, CIW does expect to see documented evidence of RI formal visits at inspection. People receive good care from a service, which is committed to quality assurance.
Page 8 5. Improvements required and recommended following this inspection
5.1 Areas of non compliance from previous inspections
None
5.2 Recommendations for improvement
We recommend the following: The SOP should be reviewed to include a summary of how the RI will maintain oversight of the management, quality, safety and effectiveness of the service including frequency of formal visits to the service. An additional SOP could also be available which is more dementia friendly. When a decision is made that the service can meet an individual’s care and support needs an initial personal plan needs to be developed, co-produced with the individual and any relative/representative (if appropriate) before the individual begins to receive care and support. In the case of an emergency admission, the initial personal plan will be in place within 24 hours of the service commencing. Personal plans should be up-dated as and when required but at least every three months. A full audit should be completed on all care files to ensure people have appropriate risk assessments that cover every risk pertinent to each person. A system should be developed to actively monitor when staff require one-to-one supervisions. All staff must have a valid DBS certificate. The service provider must apply for a new DBS certificate within three years, for staff members who are not registered with the DBS up-date service. If staff members have registered with the up-date service, the service provider must check the person’s DBS certificate status at least annually. The RI must ensure systems are in place to provide evidence that formal visits are logged and documented. The frequency of such visits and meetings is to be determined by the RI having regard to the statement of purpose but must be at least every three months. The regulations and guidance do not specify the details or format of what should be documented but we would expect to see written evidence of each formal RI visit. This should include the date the visit took place, the numbers of staff and individuals spoken with, a summary of the feedback from these discussions, an outline of the RIs observations of the premises and an outline of the RI’s conclusions from the review of events and complaints records. The service provider should consider CIW’s template and guidance on how to complete the quality of care review, which will also help them, complete their annual return in the future.
Page 9 6. How we undertook this inspection
Page 10 This was a full inspection undertaken as part of our inspection programme. One inspector made an unannounced visit to the service on the 11 December 2019 between 9:30 am and 4:30 pm and we returned on the 12 December 2019 between 12:00 pm and 3:30 pm.
The following regulations were considered as part of this inspection:
The Regulated Services (Services Providers and Responsible Individuals) (Wales) Regulations 2017.
The following methods were used:
We used the Short Observational Framework for Inspection (SOFI). The SOFI tool enables inspectors to observe and record care to help us understand the experience of people who cannot communicate with us. We toured the building and looked in 10 bedrooms. We used the King’s Fund environmental assessment tool. This tool has seven sections and a set of questions to prompt discussions this enables inspectors to assess if the service is dementia friendly. We case tracked and reviewed records for three people living with dementia. We looked at a wide range of records. We looked at three staff files, supervision and appraisal documentation, training documentation, a selection of policies and procedures, latest quality of care review, fire safety file, a selection of food menus and the activity folder. We reviewed medication practices within the service. We reviewed the SOP and compared it with the service we observed. We spoke with the people receiving a service, four members of staff, four relatives/representatives and the maintenance team. We spoke with the responsible individual who agreed for us to give feedback to the service manager during our second visit to the service.
Further information about what we do can be found on our website: www.careinspectorate.wales
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About the service
Type of care provided Care Home Service
Service Provider WOODCROFT CARE HOME LTD
Responsible Individual Andrew Snook
Registered maximum number of 22 places
Date of previous Care Inspectorate This was the first inspection under RISCA. Wales inspection
Dates of this Inspection visit(s) 11 & 12 December 2019
Operating Language of the service English
Does this service provide the Welsh Language active offer? This is a service that is working towards providing an 'Active Offer' of the Welsh language.
Additional Information:
Date Published 04/02/2020