Inspection on 16/04/08 for Woodbank

This is the latest available inspection report for this service, carried out on 16th April 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodbank 09/01/06

Woodbank 15/09/05

Woodbank 25/02/05

Woodbank 28/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodbank Woodbank Hollybank Road Woking Surrey GU22 0JP Lead Inspector Mavis Clahar Unannounced Inspection 16th April 2008 09:25 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 Woodbank DS0000013836.V361049.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. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodbank Address Woodbank Hollybank Road Woking Surrey GU22 0JP 01483 773684 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) susanhaines@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Melanie Jacobs Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bedroom 13 (Double) to be used for married couple only. Date of last inspection 5th December 2006 Brief Description of the Service: Woodbank is managed by the Methodist Homes for the Aged and is one of a number of homes administered by the organisation. Woodbank is a large detached property in a quiet residential area of Woking, close to local facilities. The home offers accommodation on two floors, the upper floor is accessible via the stairs and a lift. There are 38 single bedrooms and one double bedroom. Residents have access to a small kitchen on the first floor. The main kitchen and dining room are on the ground floor. There is some staff accommodation, which is situated on the first floor. Visitors’ parking is available at the front of the house and on the road. There is a mature, well-kept garden, which is accessible to wheelchair users. Fees are in the range of £497 to £559 per week. There is additional cost for hairdressing, chiropody and personal toiletries. Woodbank DS0000013836.V361049.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 3 stars. This means the people who use this service experience excellent quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was carried out by Mrs Mavis Clahar on the 11th April 2008 and lasted for seven and a half hours; commencing at 09:25 hours and concluding at 17:00 hours. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This initially helps CSCI (us) us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document was received by CSCI and is referred to throughout the report. The manager of the home assisted CSCI (us) on this site visit. The majority of the service users spoken to were able to express their thoughts and feelings about the care they receive. The information contained in this report was gathered mainly from observation by the inspector, speaking with a number of service users, and with care staff and from information contained within the AQAA. Further information was gathered from records kept at the home. The first part of the inspection was spent discussing and agreeing the inspection process with the manager, followed by a tour of the home, which included time spent in discussion with service users, care workers and the Chef. The manager and staff are aware of the Laws regarding equality and diversity and Equal opportunities and this was reflected in the staff mix. All service users in this home are Caucasian and reflect the population of the area in which the home is situated. All records sampled were up to date with care plans being signed by the service users or by relatives. One requirement and one recommendation of good practice were issued on this visit Please see Environment and Management and Administration outcomes for full disclosure. The final part of the inspection was spent giving feedback to the manager about the findings of this visit. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 6 The inspector would like to thank all the service users, relatives and care staff that made the visit so productive and pleasant on the day. What the service does well: What has improved since the last inspection? They have revised and enhanced their care plans documentation to ensure it meets their exacting standards of best practice and safety. They have commenced initiatives to provide better end of life experiences for service users. Medication policies have been reviewed, implemented a refresher training programme for all staff in the home dealing with medication and have introduced a comprehensive audit process to ensure procedures are adhered to by all staff at all times. The home has introduced awareness leaflets for staff and service users on falls prevention, MRSA and oral hygiene. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 7 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. Woodbank DS0000013836.V361049.R01.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 Woodbank DS0000013836.V361049.R01.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): 36 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs and service users are being assessed to ensure the home is capable to meet the needs of the service users prior to being admitted into the home EVIDENCE: Review of service users documents and identified policies demonstrated the home has a policy and procedure on admission and discharge of service users. Within the admission policy all service users must have an assessment prior to being admitted into the home. The Registered Manager, and in her absence, the senior carer who is trained in the principles of assessment of service users’ needs based on what the home says it will provide carries out all pre Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 10 admission assessments of service users prior to them being admitted into the home. The Annual Quality Assurance Assessment (AQAA) states “a full domiciliary assessment of the residents’ care needs, abilities, interests, health and spiritual needs is carried out by a trained manager prior to admission, involving the resident and representatives to ensure the admission is appropriate. Commissioned placements will also involve healthcare professionals and their assessment process”. Review of a random sample of service user’s files including one recently admitted service user, demonstrated that pre admission assessments are being carried out and relatives were being involved in the assessment process. The AQAA states “all residents at Woodbank receive a comprehensive “Residential Care management” covering all the terms and conditions of living in the home, including a full breakdown of fees and funders”. In discussion with service users’ relatives they supported this statement, and contracts for the service users tracked on this visit were available for review. Standard 6 does not apply to this home. Woodbank DS0000013836.V361049.R01.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 10 People who use the service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Practices in the home reflect service users’ needs involving the six strands of diversity: gender, age, religion or belief and disability. The home has a good and easy to read and understand care plan in place for service users and this includes appropriate risks assessments. Which forms the basis for care based on the agreed care needs of the service users and demonstrated that trained staff met service users’ health and personal care needs. The home’s medication policy on receiving, storing and administering of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers treated service users with respect and maintain their dignity and privacy when delivering personal care. EVIDENCE: Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 12 The randomly selected care plans were clear and easy to read, identifying potential and actual risks to service users and detailing how these risks would be managed. The daily work sheet along with discussion with service users and care workers demonstrated that service users care needs are fully met. The service user or relative signed the care plans to indicate their involvement in deciding what care they received. It was evidenced that care staff undertaking the development and monthly review of the care plans also signed and dated them. In discussions with service users and their relatives on the day of the visit they confirmed they were involved in the planning of their daily care. The AQAA states, “All residents at Woodbank have an individual Support Plan (Care Plan) which is comprehensive, person centred and in addition to any care plan provided by a placing authority. The support plans are based on the initial pre assessment information and residents and their families are encouraged to have direct involvement in the development of the plan, write up their personal profile and sign the plan”. We observed that regular audits and reviews are undertaken as a minimum monthly, and the home uses recognised tools such as Waterlow score and Malnutrition Universal Screening Tool (MUST) during the care planning process to support decisions made. Information contained in the home’s Annual Quality Assurance Assessment (AQAA) states “We have access to and consult with specialist practitioners such as specialist medical, nursing, dental, pharmaceutical, chiropody and therapeutic services hospitals and community health services when required”. This service enables service users to benefit from the involvement of specialist health professionals who supports the home in meeting the needs of the service users. All service users are registered with a local General Practitioner (GP) of their choice and visits are recorded, with access to specialist healthcare professionals through their GP practice as required such as sight and hearing tests which are carried out on a regular basis; and these visits are also recorded in the service user’s folder. Service users are offered access to chiropody service and weekly hairdressing facilities are available at a cost to the service users. In discussion with relatives, the manager and care workers they were extremely proud of the high standard of care they provided to all service users in the home. We were told on the day of the visit that some service users at present are risked assess as capable to self medicate. The home had a policy on selfmedication. We were told senior care staff have all received training in the receipt, recording, storage handling and administration and disposal of medicines. We observed all medicines are administered from a lockable drugs trolley. The home keeps a controlled drug register and record Medication fridge and room temperature daily. This was evidenced as correct during a tour of the home. Care staff identified as capable to administer medication are Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 13 requested to leave a sample of their signature, which is dated in the medication trolley. All service users have a recent photograph included in their personal folder and medication record, to reduce the risk of mistakes happening during medication administration. We observed that care workers wore name badges to enable visitors and service users with memory impairment to be sure of whom they are speaking with; and we also observed Service users being treated in a friendly but respectful manner by care workers. In discussion with service users who were able to understand the questions, they told us that they are treated with respect and dignity, and that they are able to make their own choice. One service user told us “I am very happy here. Everything is so nice. I have my own room; I can have as much privacy as I want”. Another service user said “We have good staff here; they do not ill treat me. I have help to choose my own clothing every day”. One relative told us “This is an excellent home; a good place for my relative to spend their last years.” We observed in the reception area, an altar with flowers, photograph and a single burning candle were in place for a recently departed service user with notification of the funeral and the relative’s invitation to the staff, and service users who wish to attend. In discussion with the manager we were told this practice is carried out for all departed service users until the day of the funeral. We were shown suitable risk assessment were drawn up for the use of the candle, which was placed in a deep bowl for safety. Woodbank DS0000013836.V361049.R01.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 15 People who use the service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Service users are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home has sought the views of the service users and considered their varied interests when planning the routines of daily living and arranging activities both in the home and community. Routines are very flexible and service users can make choices in major areas of their lives. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in pleasant surroundings and in an unhurried way. EVIDENCE: Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 15 The home employs a full time activity-co-ordinator who provides a range of activities based on the individual service user’s assessed and agreed needs, including their preferences, cultural beliefs and customs. We were told that wherever possible relatives are encouraged to participate in the planning and carrying out of service users’ activities. The AQAA states, “Woodbank employs an activity co-ordinator who focuses entirely on providing the opportunities and facilities for social care. She is assisted by a Volunteer Group who take an interest in individual residents as well as organised activities and fundraising”. In discussion with service users we were told, “we celebrate residents special days and golden moments”. On the day of the visit we observed the service users celebrating one resident’s special day with a cake baked by the chef for the occasion. We were also told that service users are provided with materials and activities to focus on reminiscence, encouraging service users to reflect on and enjoy their lives, families and achievements. Many of the service users were enthusiastic about the up coming outing to a local restaurant for high tea. The home provides a stimulating lifestyle for our service users toe have minimised the risk of a decline in their mental and physical health, through boredom, depression and lack of exercise, hobbies and games. The home has a dedicated Chaplain who provides regular services at the home. We were told that the home liaises with various local churches to provide opportunities for worship for various faiths and denominations outside of the home. The AQAA states “We try to focus on the spiritual needs of the service users, offering the opportunity to reflect, anticipate, enjoy explore and clarify feelings and beliefs”. Service users and relatives spoken to told us they have choice and they are free to go out as and when they want, so long as they sign out and in for fire purposes. The AQAA states “We value very highly residents rights to as full a life as possible, to be part of the local community and to see (or refuse to see) visitors in private”. Catering facilities are managed and carried out by the home’s chef who had a very good knowledge of the dietary needs of the service users. On the day of the inspection there were two main courses with various alternatives for service users who had changed their minds about the meal they ordered. We observed the main meal of the day being served and it was observed that grace was said publicly prior to the meal being served The inspector did not sample the lunch, but service users said the food is generally very good, tasty and the right amount. The inspector observed the presentation of the food was done in a way to stimulate appetite. The Chef told us that some service users had supplements as ordered by their GP or dietician, to maintain body weight or increase appetite. Lunch, was served in the dinning room unless a service user requested to have their meal in their bedroom. We observed care workers interacting in a friendly but dignified Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 16 manner with service users during the lunch time, sitting down beside service users and speaking to them whilst helping them with their lunches. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 17 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 18 People who use the service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The home has a satisfactory complaints policy and procedure and training in place that evidenced that service users and relatives concerns are listened to and acted upon. Robust Safeguarding adults’ policies are in place to protect the service users from abuse. EVIDENCE: CSCI Oxford/Maidstone received no complaint about the home since the last Key Inspection. The AQAA stated the home received two complaints in the last year, but in discussion with the manager she told us this statement was a mistake on her part and then produced the complaints folder to verify her mistake. We were told that a new revised complaints policy is in place and all staff has received updated training. The company has recently appointed a Director of Service Improvement who has the responsibility to ensure all complaints, comments and compliments are dealt with promptly, give clear responses to all areas of concern and to highlight the company’s complaint policies and procedures. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 18 The Manager told us that the management team are in touch with service users on a daily basis and issues raised are dealt with immediately; this reduces the incidents of formal complaints. Service users and relatives spoken to said they know how to complain and will do so if they are not happy. Their concerns are always dealt with immediately and they were satisfied with the outcomes. It was observed that the home’s guest information pack situated in reception contained a complaints procedure and policy; whistle blowing policy and the homes’ statement of purpose. It was noted that the home received a number of compliments from relatives of service users commending the staff on their kindness and understanding and for the high quality of work they perform. A copy of the most recent CSCI report is made available for visitors to the home. In discussion with care workers, it was apparent they are aware of the home’s policy and procedure on Safeguarding Adults and felt secure in the knowledge that if they had to use the whistle blowing procedure the manager and the Owners of the home would support them. During discussion with care workers it became apparent they had a full knowledge on Equality and Diversity issues relating to the service users they were responsible for. A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed needs, thereby protecting them from abuse. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 19 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 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables service users to live in a safe, well- maintained and comfortable environment, which encourages independence, and protect their privacy and dignity. EVIDENCE: The manager told us that the management and staff encourage service users to see the home as their own home. It presents as a comfortable, attractive home, which has the specialist adaptations needed to meet the service users needs. The home employs a maintenance person who ensures the home and facilities for service users are kept in good condition with records of service history available for inspection. The AQAA states, “Woodbank was adapted Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 20 with design features to enhance person centred support and assist the residents who live here. This includes small group living, en-suite toilets, specialist baths, wide corridors handrails and grab rails”. The home employs a full time gardener who ensures the attractive gardens, is well maintained and there is good access to the gardens from various parts of the home. We were told that the service users value the therapeutic benefits that outside space can bring and they enjoy the newly created sensory garden, attractive raised planted areas, the strategically placed seating and wonder paths within the garden. In discussion with service users and relatives they told us the garden is a treasure and that it was organised by the friends of Woodbank. It was noted that service users were able to personalise their bedrooms with small items of furniture, paintings on the wall and many family photographs. We observed that paper towels and liquid soap were not provided in service users bedrooms for carers’ use. A requirement was issued on this standard. Service users call bells tested were in good working order and we were told the maintenance person carries out the maintenance of the call bells. The home produced records of testing to verify this. Generally, the home presents as clean, safe, pleasant, hygienic and tidy and free from offensive odours. Random review of care workers training record demonstrated they have had training in infection control and this was evident in the storage of waste. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 21 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 30 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of the service users. EVIDENCE: The staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was adequate to meet the assessed care needs of the service users. Over 66 of care workers have attained the National Vocational Qualification (NVQ) Level 2 qualification and above with one care worker undertaking NVQ Level 3 and two are is in the process of completing NVQ Level 2 in care. Review of care workers files demonstrated that care workers had regular and up to date training to enable them to fulfil their roles. In discussion with care workers we were told they have not had any formal training in Equality and diversity at this home, but they demonstrated good knowledge about the areas within equality and diversity as related to the service users they were caring for. A recommendation was made to ensure this training was carried out and to include training on mental Health capacity Act. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 22 A random review of care workers files found that the home complied with the regulation regarding employment of staff to work in care homes Recruitment to the home is through a process of equal opportunity, and in accordance with the code of conduct and practice set by the General Social Care Council (GSCC). All care workers have Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks and two written references. Carers employed since July 2004 have history of employment included prior to commencing employment, and they are in receipt of terms and conditions of employment as evidenced in their randomly selected files. There was evidence in the care workers files that they are supervised on a regular basis. All newly appointed care workers undertake an induction programme based on Skills for Care Foundation guidelines, and this was supported during discussions with a new member of staff. The home ensures that staff undertakes the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the care workers and by checking care workers’ training files. In discussion with care workers some were able to give examples of how the home applied equality and diversity to the different needs and wishes of the service users in their care, and also within the diverse staff group. Staff files contained their up to date training records. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 23 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 38 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The acting manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home. EVIDENCE: Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 24 The AQQA contains good information that is fully supported by appropriate evidence. It includes a good level of understanding about the importance of equality and diversity and a range of evidence showing how they have listened to service users. The home demonstrates a good level of self-awareness and recognises the areas that it still needs to improve, and has clearly detailed the innovative ways in which they are planning to do this. The home fully recognises the importance of the AQQA and has used the content to inform its own quality assurance. The data section of the AQQA is mostly accurately and fully completed and supports evidence in the self-assessment section. There have been management changes since the last inspection of the home, including a new home manager for the home.. The management structure now includes one overall General Manager for the service, and two deputy managers to support her in her role. The new manager has demonstrated that she has kept herself updated on issues relating to care of service users and staff in her charge. She hold the Registered Managers Award qualification and has many years experience of caring and management. In discussion with the manager it was evident she was knowledgeable about the care needs of the service users and the training needs of the care workers to meet the identified care needs of the service users. There are clear lines of accountability within the home; each member of staff spoken to on the day of the inspection was clear about their role and responsibilities. The majority of the service users are able to be involved in the running of the home. We were told by relatives that they are encouraged and enabled to be as involved in the running of the home as their time will allow them to be. One service user said, “The manager is new, but she listens to what we have to say and then she speaks with the top people”. Minutes of the residents meetings are kept on file for review. We were informed that the home does not become involved with service users’ finance except for those service users who have asked for their spending money to be kept by the home. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature were regularly checked. Random sample of care workers’ training files demonstrated that up to date and relevant training were carried out by care workers to protect service users’ health, welfare and safety. In discussion with care workers it was evident that they had an understanding and implementation of appropriate procedures to safeguard service users, and they spoke about their understanding of promoting safe working practices based on their health and safety training. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 25 Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 26 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 4 8 4 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 2 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 27 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 13 (3) Requirement The registered person must provide liquid soap and paper towels in each service user’s bedroom to ensure staff are able to wash and dry their hands, thus preventing infection, toxic conditions and the spread of infection in the home. Timescale for action 16/07/08 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 OP30 Good Practice Recommendations Ensure all staff receive training in Equality and Diversity and also In Mental Capacity Act 2005. Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Woodbank DS0000013836.V361049.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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