Inspection on 22/08/07 for Dean Wood Manor

This inspection was carried out on 22nd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dean Wood Manor 26/02/09

Dean Wood Manor 22/05/08

Dean Wood Manor 20/12/06

Dean Wood Manor 11/05/06

Dean Wood Manor 27/02/06

Dean Wood Manor 11/10/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Dean Wood Manor Spring Road Orrell Wigan Greater Manchester WN5 0JH Lead Inspector Rukhsana Yates Unannounced Inspection 22nd August 2007 09:30 X10029.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 Dean Wood Manor DS0000064122.V350616.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 and Care Homes for Adults 18 – 65*. 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. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dean Wood Manor Address Spring Road Orrell Wigan Greater Manchester WN5 0JH 01942 223982 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) deanwoodmanor@mimosahealthcare.com www.mimosahealthcare.com Mimosa Healthcare Limited ** Post Vacant *** Care Home 50 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Old age, not falling within any of places other category (43), Physical disability over 65 years of age (8) Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 50 service users, to include: Up to 43 service users in the category of OP (over 65 years of age) Up to 8 service users in the category of PD(E) (over 65 years of age) Up to 7 service users in the category of MD (Mental Disorder under 65 years of age). The service should employ a suitably qualified and experienced Manager who is registered by the CSCI. The Home must be appropriately staffed at all times. The numbers and skills mix of the staff must meet the needs of service users. 20th December 2006 2. 3. Date of last inspection Brief Description of the Service: Dean Wood Manor is located off the main Orrell to Standish road. The premises comprising Dean Wood Manor are based around an original Grade II listed building that has been extended to provide accommodation to a total of 50 people. The gardens surrounding the home are extensive and wellpresented. Car parking for visitors is good. The registration categories (the groups of people who can be admitted) allow a maximum of 43 elderly people with nursing and/or personal care needs, as well as up to 8 elderly people with a physical disability, and up to 7 younger adults (under 65) with a mental disorder to be accommodated at the home. Dean Wood Manor is part of the Mimosa group of homes. The Mimosa philosophy is Where people matter. The stated aim is to provide all residents with the kind of individual care they need, whilst maintaining their independence, dignity and freedom of choice. Fees take account of the size of room the person occupies, as well as the extent of personal and/or nursing care they require. Fees range from £338.07 to £477.07 per week in the main part of the home and £699 to £754.48 per week in the Woodlands suite. Additional charges are made for hairdressing and transport. Fees take account of the size of room the person occupies, as well as the extent of personal and/or nursing care they require. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection at Dean Wood Manor took place over the course of one day and included a site visit to the service. The inspector looked at records the home holds on residents (care plans) and other records the home needs to keep to ensure the home is being run properly, for example activity records, menus, staff files and staff training records. The inspector also looked around the building. To find out more information the inspector spoke to several residents and a visitor. The Acting Manager, two care staff and catering staff were also spoken with. Staff were also watched as they went about their work. The service was inspected against key standards for homes for older people to see how well it was meeting a range of needs. These standards cover moving in, the care provided, daily routines and lifestyle, complaints, safety, comfort and cleanliness, how staff are employed and trained, and how the service is managed and developed. The term preferred by the people consulted during the visit was “residents”. This term is, therefore, used throughout the report when referring to those living at the home. What the service does well: From speaking to residents and visitors it was clear that, in the main, they were happy with the care provided. Some of the comments were: “The staff are lovely here. I can’t fault any of them”, “I’m amazed at how kind and caring they are”, “The people here are very nice and the place is very nice”, “He likes it and seems to be well looked after” (relative). One nurse said of the younger adults at Woodlands, “There has been a big difference in them all”. Relatives said they could visit at any time and staff always made them feel welcome. The meals at the home are varied and well balanced. Residents who were able to comment said they liked the food. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1; 3 (Older People) & 1; 2 (Adults 18-65): Standard 6 is not applicable to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents do not always know what to expect from the service due to limited information and incomplete pre-admission assessments. EVIDENCE: The Woodlands Suite has been operational for some months. At the last inspection, referrals to the unit had ceased due to concerns about staffing and a lack of clear remit for the unit. This has greatly improved and referrals are now being made. The service has a new Outreach Coordinator and Registered Mental Nurse, both of whom have experience and enthusiasm. They are taking the lead in meeting with consultants and mental health professionals and Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 9 referral agencies to ensure that people admitted are suitable for the service and the service can meet their needs. Written objectives have been drafted so that there is a clear remit for the unit with the emphasis on rehabilitation and meeting mental health needs in a supportive environment. Work has started on producing a Service User’s Guide. In the main part of the home, shortfalls from last inspection remain. The file of recently admitted resident contained a very brief pre-admission assessment which was not dated or signed. There was no photograph and no draft objectives, life history or social needs recorded, although reference had been made to carer preference, for example, “Prefers female carers”. The Acting manager agreed that the lack of management and consistency within the home had meant that care planning information had not improved although she herself had identified the need. The Statement of Purpose is generic to the home and needs to be re-drafted and updated. It describes the philosophy of the home and facilities and services, and includes the complaints procedure and room sizes. It is not in different formats and residents consulted were not aware of the document and did not recall being given a Service Users’ Guide. At present, a number of residents are having their needs reassessed by Social Workers. There continues to be a large percentage of people with dementia care needs, and a need to make sure their specialist needs are met. For example, care plans to not identify specific dementia related instructions for staff, and the environment does not have orientation aids. There has been a move recently, to advertise for RMNs instead of general nurses in recognition of the older residents’ mental health needs. The Acting Manager has experience of specialist dementia care provision and agreed that there are shortfalls as identified. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7; 8; 9; 10 (Older People) & 6; 9; 16; 18; 19; 20 (Adults 18-65): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health and care needs were, in the main, met but care plans did not fully reflect the comprehensive range of support needed by each resident. EVIDENCE: Four care plans were examined (1 adult under 65 and 3 older people). The care plan for the resident under 65 had comprehensive information relating to personal, social and health care needs. Each area of risk had a separate Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 11 record. Daily entries in care notes were completed and gave a good indication of the care provided and the resident’s well being, Daily living skills were assessed and care plan around these subject to weekly review, including areas of time management, cooking, budgeting, road safety, household skills, personal hygiene, laundry, shopping, health awareness and social skills. Files were well organised and rehabilitation plans and progress simple to see and understand. As at the last inspection, better care plans for over 65s are in the process of being introduced but not yet completed. The Acting Manager has identified shortfalls in care planning information and has completed two in order to provide examples of what a good care plan should look like and what it should contain. One of these examples included pressure area, nutritional, falls and moving and handling risk assessments, and actions in the care plans relating to these. The plans also included “A day in the life” of the resident describing the person’s preferred daily routine. The care plans needing improvement lacked actions related to risks identified and specific care planning information relating to meeting residents’ dementia care needs. During previous inspections requirements have been made for all aspects of health, personal and social care needs to be identified and planned for and this remains relevant. Issues around training for nursing staff and involvement in all care staff in contributing to care planning remain as identified at the last inspection. Residents able to comment were happy with the care provided. Examples of comments made are; “The staff are lovely here. I can’t fault any of them”, “I’m amazed at how kind and caring they are”, “The people here are very nice and the place is very nice”, “He likes it and seems to be well looked after” (relative). One nurse said of the younger adults at Woodlands, “There has been a big difference in them all”. Care plans contained details of visits by health care professionals including doctor, chiropodist and dentist. Procedures were in place that described safe medication handling. Nursing staff are responsible for the administration of medication. Where risk assessed and willing, residents self-administer. The home uses a monitored dosage system supplied by the local pharmacy. Accurate records were in place for receipt and administration. A separate facility is provided for the storage of medication (on each unit). A lockable drug trolley is provided which when not in use are secured to the wall. A separate system for recording the administration of controlled drugs is in place and separate storage is provided. Medication storage was orderly with no evidence of overstocking. The home uses a monitored dosage system supplied by a local pharmacist. A sample of MAR sheets was examined and was found to be clear and up to date. During the inspection, staff were observed to treat residents with respect and consideration. Residents were observed to be dressed in clean, well maintained clothing. Staff were observed knocking on doors before entering rooms. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12; 13; 14; 15 (Older People) & 12; 13; 15; 17 (Adults 18-65): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy the social activities and meals, but the social needs of people with dementia are not suitably addressed. EVIDENCE: Since the last inspection, an Activities Coordinator has been employed, has introduced a range of activities, and is looking at courses and resources relating to activities for residents with dementia. She has introduced a monthly Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 13 newsletter and maintains good, individual records that note whether each resident observed or took part in an activity. Examples of activities undertaken include sing-a-longs, dominoes, reminiscence, entertainers, skittles, ball games and crafts. The records for one person in short term care showed that the Coordinator had a chat with him in his room to get to know him and to encourage him to participate. Activities are also discussed in minutes of residents and relatives meetings. The Outreach Coordinator in the Woodlands Suite has introduced a stronger rehabilitation function. A whiteboard on the wall shows residents the various activities and resources available to them during the week. There has been good progress in ensuring more use of community facilities. A computer for residents is available in the lounge. Residents wishing to maintain their religious links were encouraged and enabled to do so. Resident’s religious beliefs are noted in care plans. The home had an open visiting policy. A resident said, “I get a lot of visitors, they can come anytime.” Residents can see visitors in any area or in their rooms. A visitor’s book showed the times people had visited. One visitor spoken with said staff always welcoming when she visited. Residents who were able to comment expressed satisfaction with the care provided. Residents said they had choices where they wished to sit, when they got up, when they went to bed and what clothes they wore. A high percentage of residents (in the main part of the home) have memory and communication difficulties so were unable to confirm they were able to exercise choice. However observation of care practice indicated residents could make some choices in regard to the meals and where they spent their day. Resident’s rooms are personalised and residents are able to bring personal items in the home. As previously noted care records would benefit from having more personal detail (particularly due to residents’ communication difficulties). This would recognise the knowledge existing staff have and provide a guide for staff, regarding how each resident likes their care to be delivered. Four-week menus are in place. The menus were inspected and were found to be well balanced and varied. A choice is offered at every meal. Residents not able to manage their own lunch were supported appropriately and given time, staff spoke to them explaining what the food was and checking if they were ready for some more. Residents who commented expressed their satisfaction with the quality, quantity and choice of food provided. Tea, coffee or juice was available to drink. Residents living in the Woodlands Suite prepare their own breakfast, tea and snacks. The unit has a hob and microwave but no cooker. Two people are now at the stage of shopping for themselves, and would benefit from the provision of a cooker and additional fridge to further develop their skills in organising and preparing their food. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16; 18 (Older People) & 22; 23 (Adults 18-65): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives knew who to go to with concerns and complaints, and appropriate systems were in place to safeguard residents’ welfare. EVIDENCE: The home’s complaint procedure is displayed at the main entrance and sets out the process a person should follow if they wished to make a complaint or raise a concern, including with organisations outside of the home and Mimosa. A copy was not displayed in the Woodlands suite, and the procedure will need to be included in the younger adults’ service users’ guide. Information received prior to the inspection indicated that no complaints had been made. No complaints have been received by the CSCI (Commission for Social Care Inspection) since the last inspection. A system is in place to record any concerns or complaints. The three residents whose care was looked at were unable to indicate if whether they could speak to staff about any problems. However other residents spoken with and relatives knew whom to approach if they had a concern or complaint. At the last inspection it was found that the home ensures all staff completes a POVA and CRB (Protection of Vulnerable Adults Register/Criminal Records Bureau) before they commence work. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 15 However, during this visit, records showed that one person started a few days before the POVA check was received. Training in the signs and recognition of abuse is covered during induction and in NVQ (National Vocational Qualification) training. Mimosa have also provided training sessions for the staff team with the aim of raising awareness so that residents were kept safe from abuse in any form. In conversations, staff were able to confirm that they understood what “abuse,” meant, and what they would do if they saw abuse taking place. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19; 26 (Older People) & 24; 30 (Adults 18-65): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the décor, fabric and furnishings continues to improve, providing residents with a clean and well-maintained environment to live in. EVIDENCE: The environment is generally safe and clean. For residents with some level of confusion or dementia, colour coded bedroom doors assist them to find their own rooms. Other signage would be useful to residents, which could include Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 17 personalised plaques, which would help with identification of bedrooms. Other signage round the home was not designed for residents that are very confused. Lighting in the corridor and front lounge was dim. Toilet signs needed to be brighter and clearer. Toilets were close to communal areas. A programme of decoration was seen to be taking place. All bedrooms have been refurbished in the last 12 months. The rooms were decorated in magnolia to create a blank canvas for new residents but they could choose their own colours if they wished. The Woodlands Suite has been completely refurbished. All the bathrooms have been decorated and painted in warm colours to make the rooms less institutional. Pictures and mirrors have been added. The Woodlands suite had seven bedrooms (one had en-suite facilities) all bedrooms varied in size, were well decorated and furnished adequately. Communal areas included a lounge with dining area and a kitchen. Residents were expected to shop and cook for themselves with staff support if they needed it. The laundry was sited away from food preparation areas and was seen to be clean and orderly. Sufficient and suitable equipment was provided. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27; 28; 29; 30 (Older People) & 32; 34; 35 (Adults 18-65): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers and training arrangements ensure that care needs are met. However insufficient kitchen staff cover can compromise choice for residents, and lapses in recruitment practices potentially place people at risk. EVIDENCE: On the day of the visit staffing in the main part of the home comprised of the nurse in charge, 2 senior care assistants, 3 care assistants, the cook, domestic staff, a laundry assistant and a maintenance person. In the main this appeared sufficient to meet the residents needs. But kitchen staffing required review and no holiday cover had been instigated for the next day until prompted during inspection. The deployment of one cook and one kitchen assistant servicing the main home and the Woodlands Suite appeared insufficient in terms of maintaining choice for all residents and sustaining a cleaning schedule. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 19 During the visit staff were observed to respond speedily to requests made for assistance made by residents. It was also evident from staff comments they enjoyed working at the home. The Woodlands suite is staffed separately. Normally during the day there is one RMN (Registered Mental Nurse) and one or two care workers supporting three residents. They were also observed socialising with residents. It was also evident from staff comments they enjoyed working at the home. The files of staff employed looked at, except one recent recruit, showed all necessary recruitment checks had been undertaken. All contained: written application forms, 2 references, Criminal Records Bureau (CRB) check and verification of identification. Interview notes were on each individual file. Each member of staff had completed an equal opportunities monitoring form. The staff training schedule is kept on computer and was made available. In addition three individual staff training records were examined. There was evidence that new staff undertake induction training that meets the National Training Organisation (NTO) specifications following which foundation training is undertaken. Staff had undertaken a range of training. Courses completed by staff including health and safety, food hygiene, moving and handling, fire safety, life support and dementia care. Staff spoken with were in the main satisfied with the training provided. They also confirmed they had completed a lot of courses in the past year. Training was also open to domestic staff. While the range and frequency of training has improved staff spoken with identified training courses they felt would be beneficial. This included care of the dying, challenging behaviour and dementia care. Another area, which needs to be considered, relates to the provision of service specific training for support staff working on the Woodlands suite. For example training covering specific mental health conditions and challenging behaviour. Since the last inspection progress has been made in regard to the provision of NVQ (National Vocational Training) for staff. The percentage of staff in receipt on NVQ (National Vocational Qualification) level 2 now exceeds 50 . Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31; 33; 35; 38 (Older People) & 37; 39; 42 (Adults 18-65): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the service have benefited residents. The absence of a permanent manager has, however, resulted in several areas requiring attention. Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 21 EVIDENCE: Since the last inspection the registered manager has resigned. The company have had some difficulties in finding a suitable person to fill the position. A new manager has now been recruited and is due commencing employment in September 2007. An Acting Manager was in the home during the inspection, auditing and managing for 2-3 weeks. Some progress had been made with regard to staff supervision. Regulation 26 visits had been conducted, as had external Mimosa group audits. The external audits were completed by another area manager and include all areas of the running of the home e.g. grounds and health and safety. Full policy and procedures for the Mimosa group were seen in three files in the office these were comprehensive and included proformas for managers to complete e.g. examples of response letters. Wigan Metropolitan Borough had awarded Deanwood Manor 4 stars following a threeday audit. Surveys had been completed as part of this process. The system for safeguarding resident’s money was in place and for the one resident checked this was seen to correspond to the amount recorded. Arrangements for environmental maintenance were satisfactory. A file is kept in which staff record faults/ areas needing repair and the maintenance person marks these off as they are completed, or if he can’t do them he reports this to the office. The maintenance person completes portable appliance testing on a twelve-month cycle. The water had been tested for legionella and all water outlets tested by zone on a bi-monthly basis. All fire equipment is serviced and tested regularly. Fire training is provided for staff on a rolling programme of training that staff are recalled to attend 12 monthly. Accident records were examined. There is currently no analysis, other than noting statistics, of accidents occurring in the home. This should be addressed so that patterns can be identified and risk assessment and planning instigated as necessary. Dean Wood Manor DS0000064122.V350616.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 2 X 3 2 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 2 34 X 35 3 36 2 37 X 38 3 Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement To ensure people have the information they need before they move in and during their stay, a service users’ guide must be produced and provided to current and prospective residents. To ensure all care needs are identified and they receive the care they need thorough assessments must be completed and cover all care needs identified in Standard 3. Timescale 15/02/07 not met. To ensure residents receive the care they need, care plans must include clear guidance to staff as to the action they should take to meet needs in each area. Timescale 1/3/07 not met. To ensure the safety of residents, robust recruitment procedures must be followed for all staff appointments. Timescale for action 30/01/08 2. OP3 15(1) 30/10/07 3. OP7 15(1) 31/01/08 4. OP29 18 20/09/07 Dean Wood Manor DS0000064122.V350616.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 OP8 Good Practice Recommendations To ensure the knowledge care staff have about residents care needs and preferences is documented consideration should be given to increasing their involvement in the formulation and maintenance of care plans. Social activities should be developed that meet the particular needs of residents with dementia. Work should continue to improve signage and lighting (in the main part of the home) to assist residents to find their way around the home. In order to make the home more homely for residents plans should be made to replace the vinyl flooring in the corridors (main part of the home). Staffing levels in the kitchen should be reviewed to ensure suitable cover at all times. In order to equip staff with the skills and knowledge they need to care for residents with mental health needs, more training in mental health conditions and challenging behaviour should be provided for care staff working on the Woodlands suite. 2. 3. OP12 OP19 4. OP19 5. 6. OP27 YA33 Dean Wood Manor DS0000064122.V350616.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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. 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