Inspection on 14/02/07 for The Woodlands

This inspection was carried out on 14th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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

The Woodlands 22/01/08

The Woodlands 10/08/05

The Woodlands 28/06/05

The Woodlands 04/01/05

The Woodlands 20/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Woodlands 176 Alcester Road Studley Warwickshire B80 7PA Lead Inspector Deborah Shelton Key Unannounced Inspection 14th February 2007 09:20 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 The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Woodlands Address 176 Alcester Road Studley Warwickshire B80 7PA 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) 01527 852815 01527 852815 Dr M Crooks Mrs M Crooks Mrs Wendy Louise Lewis Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: The Woodlands is located on the outskirts of Studley within reach of a variety of shops and other facilities. The home is situated on a bus route to Studley, Redditch and Alcester. The home was originally a care home for seven people; in 1994 it was extended and now provides personal care for 18 older people. The home is fully accessible to users throughout and has a shaft lift giving access to the first floor. Seven bedrooms have en-suite facilities and the home has two lounges and a conservatory, all of which are located on the ground floor. There are car parking spaces to the front of the house. The current scale of charges are £287 - £600 per week. Additional charges are made for chiropody, hairdressing and toiletries. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place between the hours of 09:20am and 5.40pm on Wednesday 14 February 2007. The manager was on duty along with the deputy, one senior and one care assistant and the cook. Seventeen people were living at The Woodlands. Two residents were ‘case tracked’, this involves finding out about the individual’s experience of living in the care home by meeting with them, talking to them and their families (where possible) about their experiences, looking at their care files, looking at their environment, discussions with staff on duty and reviewing staff training records to ensure training is provided to meet resident’s needs. Documentation regarding staffing, health and safety, medication and complaints was also reviewed. The inspector was introduced to a majority of the people that live at The Woodlands and conversations were held with seven people. Two visitors were spoken to during the inspection. The inspection process enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. Commission for Social Care Inspection comment cards were sent out to residents and relatives. Three responses were received from relatives and three from residents. Their comments are included in the main body of this report. The inspector wishes to thank the manager and her staff for the hospitality on the day of inspection. What the service does well: Staff were friendly and helpful and appeared to have a good working relationship with each other and with residents. Visitors were made welcome and offered refreshments. Residents all commented that the staff were kind, patient and would do anything for you. Some of the comments received by residents and relatives regarding life at The Woodlands are as follows: “There are no problems here at all” “If I had any worries staff would sort them out and I would speak to staff all of the time, I have no worries” The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 6 “I like to go into the garden, its nice here” “Its all good here” “The staff are very nice” “Staff very caring and gentle” “Very good management” “Excellent care and attention, dedicated staff, very happy with the level of care” The manager has a wealth of knowledge regarding the care needs of those that live at The Woodlands and is dedicated to meet these needs. The quality assurance system at the Home ensures that residents are consulted about the care that they receive and areas for improvement are identified and acted upon. The Woodlands provides a homely atmosphere with fixtures and fittings that are in a good state of repair. What has improved since the last inspection? What they could do better: From information obtained on the day of inspection and from comment cards received by the Commission for Social Care Inspection it would appear that insufficient activities are provided for residents. Records seen did not demonstrate that regular activities take place and some of the residents spoken to said that they were bored. On the morning of the visit residents in the lounge were staring into space, some residents enjoyed singing when music was put on. Activities should be provided to meet the individual needs of those living at the Woodlands, these should be available on a regular basis to increase the sense of wellbeing for residents. The information contained in care plans was comprehensive. The care plans reviewed were cluttered and contained a lot of out of date information. The manager confirmed that this information would be sorted out immediately. Residents and/or relatives are involved in the care planning process on an annual basis or as care needs alter. Some health and safety issues require addressing as a matter of urgency. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 7 Portable appliances have not been checked since 2003. All staff must undertake mandatory training on a regular basis, there was no documentary evidence that all staff have undertaken fire, moving and handling, food hygiene and first aid training recently. Two staff were witnessed moving a resident from a chair using unsafe handling techniques during the inspection. 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. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The pre-admission process provides staff with the information needed to meet the health and social care needs of residents. EVIDENCE: The care file of the most recently admitted resident was reviewed to evidence whether pre-admission assessments are undertaken and to review the documentation used during this process. Standardised documentation is used in the form of a tick list with space for additional comments. Questions are asked regarding hearing, sight, communication, cultural needs, risk of falls, continence and medication amongst other things. Documentation is comprehensive and enables sufficient information to be gathered before the manager agrees the placement at The Woodlands. The manager then writes to the potential resident and confirms that the Home are able to meet their The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 10 needs. Care plans provided by Social Services also form part of the assessment when applicable. The manager confirmed that residents are able to look around the Home, stay for a meal or stay for a day or two before deciding that they wish to move into the Home. The care file reviewed demonstrated that this resident had stayed at The Woodlands for two days before agreeing to move in on a permanent basis. Potential residents are given a copy of the Service User’s Guide and the Statement of Purpose during the pre-admission assessment. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The recording of resident’s health, personal and social care needs are good and give staff detailed guidance to enable them to meet the care needs of those that live at The Woodlands. Residents have good access to a wide range of health professionals which results in their healthcare needs being met. Systems and practices regarding storage and administration of medicine are good. The Home’s policies and procedures for dealing with medicines protect residents from risk of harm. Residents are treated with respect and their rights to privacy and dignity are maintained The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 12 EVIDENCE: Two care files were reviewed including the file of the most recently admitted resident. Care files contained standardised documentation. Documentation from external professionals such as dietician, district nurse etc are kept in care files. Evidence was available to demonstrate that residents receive regular input from optician, district nurse, GP and dentist. Various risk assessments such as pressure area, nutritional screening and manual handling were in place and reviewed on a monthly basis. Details contained in care plans were comprehensive and would give sufficient information to enable staff to meet the care needs of residents. Acceptable methods are implemented to monitor weight gain or loss for those residents who are unable to weight bare and therefore unable to stand on the Home’s scales. Therefore ensuring that the weight of all residents at the Home is monitored. One of the care files reviewed required sorting as there was a lot of out of date paperwork, which made it difficult to find information. The manager showed the inspector other files that had been put into good order with old information archived. The manager confirmed that this file would be sorted immediately. The weight records in one care file showed a weight loss of one stone in two months. There was limited evidence of the action that the Home were taking to reduce further weight loss. Residents or their representatives are involved in the annual review and would sign documentation in care files to evidence that they have been involved in this process. The manager confirmed that residents/representatives would also sign care files if there were a major change in care needs. The deputy manager audits daily records and ensures that care plans are updated with any significant information. The manager is responsible for writing all care plans. During discussions it was noted that the manager has an in-depth knowledge of the needs of those under her care. Medication systems and practices were discussed with the manager. There are no controlled medications in the Home, a controlled medications book and suitable storage facilities are available should controlled medications be required. All records seen were correct and up to date. Copies of medical prescriptions are kept on file. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 13 Medication records, systems and practices in the Home were good and various areas of good practice were noted such as photographs of residents on each medication administration record and staff signature sheets. Staff were seen to be polite and friendly and residents appeared to have a good relationship with them. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The current arrangement for activities and entertainment are limited and so therefore do not provide adequate recreation or motivation for residents which may result in boredom and low self-esteem. The service ensures that visitors are made welcome and the residents’ benefit from visits from family and friends. Residents were happy that they still had some control over their lives and the choices that they make which improves their sense of wellbeing. Meals are well presented, wholesome and provide residents with a nutritious and balanced diet. EVIDENCE: An activity programme is on display in the manager’s office, this is used as a guide for the activities that can take place but if residents do not wish to undertake a particular activity they will be offered an alternative. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 15 Activities undertaken are recorded in an activity logbook. This is used to record the activity, who attended and whether or not they enjoyed the activity. Records had not been completed on a regular basis. Documentary evidence showed that activities took place very regularly (daily in some months and every other day in others) up until June 2006. Records commenced again in December, however there was limited documentary evidence available on the day of inspection to demonstrate that regular activities took place. Activities were recorded on an ad hoc basis in January 2007 and no records were available to demonstrate that any activities have taken place in February 2007. The manager stated that activities do take place on a regular basis. Unfortunately staff do not always record them. A separate logbook is available to record any activities for those residents who prefer to or are unable to leave their bedrooms. Records had not been completed since July 2006. There was therefore no evidence that any activities have taken place with these residents. Feedback from the Commission for Social Care Inspection questionnaire relating to activities is detailed below: Always Usually Sometimes Never 1 2 Comments Very few inside or outside activities. More activities would help to promote mobility. No activity programme. Are there activities arranged by the Home that you can take part in? Two residents spoken to on the day of inspection commented that they enjoyed the exercise to music, which sometimes happens, but they really enjoy singing. Other comments received on the day of inspection are as follows: “Everyone is totally bored and un-stimulated, sometimes they put on music and leave the television on and the sound is loud”. “Residents get bored and their mental health goes downhill” “They don’t do anything in the day” “There are no planned activities and nothing going on” “There is nothing to do and it is boring, there is no fresh air, we never go outside at all and there is nothing at all to do”. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 16 “I am looking forward to the warmer weather because I enjoy sitting in the garden and staff take me to the pub in my wheelchair which I really enjoy”. Nine residents were sitting in the lounge watching a film on the afternoon of the inspection. A member of staff was sitting in the lounge with residents chatting about the film and other topics of interest. Residents appeared to be enjoying the film and were at ease in each other’s company. Visitors were seen in the lounge. Staff offered them refreshments and appeared to have a good relationship with them. The Home has an open visiting policy and visitors are welcome at any time. Two visitors were spoken to. It was noted that staff keep them updated regarding their loved one’s health and wellbeing. They confirmed that they are made to feel welcome. Throughout the inspection residents were seen to be offered a choice of drinks and snacks such as tea or coffee and biscuits. Fruit bowls were located around the Home and residents were seen helping themselves to bananas. The manager discussed how residents are given choices on a daily basis. Staff are encouraged to give visual choices as well as asking questions. Residents are given the choice of male or female carer. The key worker system is in place, however residents are able to request assistance from a particular member of staff if they wish. The manager said that residents are given a choice of everything from times of getting up, going to bed, what clothes they wish to wear, when and where they eat and where they sit. The manager tries to encourage a homely environment and residents have recently been involved in choosing the colour of decoration and curtains. One resident commented, “I am free to do as I please”. The chef works between the hours of 8am – 6pm and provides a full range of meals including breakfast of cereal or a cooked breakfast, a sandwich or snack lunch and a main evening meal. Suppertime snacks such as beans or eggs on toast or sandwiches are provided as required. A diary is used to record meal choices and any alternatives from the menu that have been requested. Evidence was available to demonstrate that residents are given a choice of meal and that they ask for alternatives from the menu and their wishes are catered for as much as possible. Staff were seen assisting residents to eat their meals in a patient and caring manner. Comments received from residents during conversations with the inspector regarding the meals varied, details are recorded as follows: “The food is nice and there is plenty of it” The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 17 “I like the puddings but the main meals are horrible”. “You get four big meals a day, I can have a cooked breakfast, I really like fish which they would give me every day if I want” “The food is not good and I am not looking forward to it, there is enough of it but it doesn’t taste nice, I am not sure what is for tea tonight”. Feedback from the Commission for Social Care Inspection questionnaire regarding meals is detailed below: Always Usually Sometimes Never 2 1 Comments Sandwiches are well presented but the bread and often the fillings are quite dry. Every effort is made to find food to my liking. Do you like the meals at the Home The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Complaints are handled objectively and service users are confident that their concerns will be listened to and acted upon. Systems are in place to protect residents from the risk of abuse, increasing their feeling of safety and their quality of life in the home. EVIDENCE: No complaints have been received by the Home or the Commission for Social Care Inspection since the last inspection. The complaints policy is discussed at every residents’ meeting (6 meetings per year). The manager reported that residents are asked individually if they have any concerns. There have been no changes to the complaints policy since the last inspection. All three relatives who responded to the Commission for Social Care Inspection comments cards stated that they are aware of the Home’s complaints procedure. One comment made reported, “concerns are always acted on”. Three residents also responded to the Commission for Social Care Inspection comments cards, all stated that staff listen and act on what they say. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 19 Comments received are as follows: “Concerns are always followed up”. “Very few complaints but always dealt with satisfactorily”. There have been no allegations of abuse. Various policies and procedures are available regarding the protection of vulnerable adults. There have been no changes to these policies recently. The policy and practices were judged as exceeding the minimum standards at a previous inspection and were therefore not reviewed at this inspection. All staff have attended protection of vulnerable adults training recently. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of the environment within this Home is generally well maintained providing an attractive, hygienic and homely place to live therefore improving the quality of life for residents. EVIDENCE: The bedrooms of those residents being case tracked were reviewed as well as other bedrooms and communal areas. The Home has two lounges and a conservatory that is used as the dining area. Communal areas provide furnishings that are in a good state of repair. The dining room was nicely laid out for dinner. No unpleasant odours were noted in any areas of the Home. Residents who responded to the Commission for Social Care Inspection comment cards reported that the Home is always fresh The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 21 and clean and one resident commented that there is “very rarely any unpleasant smells”. The large lounge required some re-decoration in places as marks were noted on the ceiling, skirting boards, window sills and doors frames. Although the lounge door has a magnetic hold open device linked to the fire alarm system, this door was also being wedged open with a wooden door wedge. Keeping doors open in this manner compromises fire safety. Doors must be kept open in a way that is acceptable to the fire service. The laundry was in good order. A control of substances hazardous to health risk assessment was on display on the wall. Bedrooms had been personalised with pictures and ornaments. A shaft lift provides access to all upper floors of the Home. All areas including bathrooms were clean and hygienic. The enclosed rear garden is well maintained and residents said that they enjoy going outside in the gardens in warmer weather. The issue regarding the “lean too” which was previously noted as requiring repainting and storage of items in a resident accessible area have been addressed. In general The Woodlands provides a homely atmosphere with fixtures and fittings that are in a good state of repair. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The number of care staff with an NVQ 2 qualification will help to ensure that the skill mix of staff on duty will support meeting the needs of residents. The employment of staff is carried out in accordance with the homes’ policies and procedures ensuring that residents are supported and protected Improvements are needed to the amount of induction and ongoing mandatory training undertaken. Lack of training might reduce the care staffs’ competence and could result in the risk of harm to the residents. EVIDENCE: A copy of the duty rota was taken for reference. Seventeen staff are employed including the manager, deputy and a chef, cook, kitchen assistant, laundry assistant and domestic (who also completes care duties). Duty rotas do not clearly demonstrate the full names of staff or their function. For example the rota records “domestics” next to four names, however it is understood that these staff are laundry, catering and domestic. It is therefore difficult to identify who is on duty providing which service to the residents and whether sufficient time is being allocated to these tasks. The duty rota for 12 The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 23 – 18 February 2007 was reviewed and it was noted that staffing levels varied on a daily basis. The minimum number of staff on duty is two and the maximum four, for short periods of time. The manager is not counted in staffing numbers. The manager must ensure that duty rotas clearly demonstrate the number and job role of staff on duty on a daily basis. There were no domestic staff on duty on the day of inspection and during discussions it was noted that care staff undertake domestic duties on some days each week. It was noted during the morning of this inspection that staff had little time to spend talking to residents. Staff are currently undertaking non care (cleaning) and care duties. Upon entering the Home at the start of the inspection the senior member of staff on duty was completing cleaning tasks. On a few occasions during the morning one resident was getting agitated and arguing with other residents in the room. Visitors to the Home tried to calm the situation and the manager tried to relieve the tension. Visitors commented that residents regularly argue and fight and they have to go and look for staff to sort out the problem. Comments received from the Commission for Social Care Inspection feedback questionnaire sent out before the inspection are detailed below: Always 3 Usually Sometimes Never Comments Staff always put themselves out to sort out any concerns and then report back. Are staff available when you need them Comments received by residents on the day of inspection regarding staff are detailed below: “Staff are all nice, friendly and kind” “Staff chat to me when they get me up in the morning” “I use my call bell and staff come quickly to close my curtains or for absolutely anything” “Everyone is really nice and friendly” A copy of the most up to date training matrix was taken for review. This document records that six staff have undertaken a national vocational qualification in care. At least 50 of the staff employed at this Home have The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 24 undertaken this qualification. This goes some way to ensuring that the staff group are qualified to be able to meet the needs of those under their care. Two staff files were reviewed to evidence the recruitment processes. Files seen were in good order and easy to read and understand. All applicable details such as criminal records bureau checks, application forms, references, proof of identity, training certificates and supervision notes were available in staff files seen. The national training organisation’s induction procedure was put in place at the Home in September 2006. The manager explained the process involved. Staff must undertake induction training within six weeks of employment. There was limited documentary evidence to demonstrate how staff are proving competence at elements of the induction training. The Home’s training matrix records training undertaken with date completed. This document identifies that all staff have undertaken abuse awareness and whistle blowing training in February 2006. However there is no documentary evidence to demonstrate that all staff have undertaken any fire training within the last twelve months. There is no date for training recorded for three staff and other staff have not had training recently, some of the training was undertaken as far back as 1997. To ensure the safety of residents in the event of a fire staff must undertake regular fire safety training. Other mandatory training such as moving and handling, first aid and food hygiene have not been undertaken by some staff recently. The manager and staff confirmed that payment is made to staff for training days, transport or payment for transport is arranged for those staff attending training days. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home has an experienced manager who has an in depth knowledge of the needs of those under her care. There are systems in place to ensure that the quality of the service provided meets the needs and expectations of the Service users who live at the Home. Resident’s financial interests are safeguarded. Not all health and safety issues have been addressed to ensure that residents live in a safe environment. This could put residents at risk. EVIDENCE: The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 26 The manager has worked at the home for over thirteen years in many job roles. The manager is enthusiastic and dedicated to meet the needs of residents in a homely and caring manner. The manager undertakes update training as necessary. A comprehensive quality assurance policy is in place covering many aspects of life at the Home, staff training, policies and procedures and supervision. The system details the area to be reviewed plus the frequency of review. Quality assurance systems are based upon the national minimum standards and requirements. The results of any satisfaction survey are displayed in an easy to read and understand format in the entrance hall. The Home do not hold any funds on behalf of residents. Resident’s families are sent itemised bills for any expenditure. The Home keep a stock of toiletries that residents can purchase and they are able to have their hair done by the visiting hairdresser. Families or advocates are invoiced every three months. Copies of all receipts are kept at the Home. All records seen were satisfactory. Records were reviewed to evidence whether the health and safety of staff and residents is maintained. Portable appliances have not been checked since 2003, the manager was aware that all portable electrical equipment should be checked on an annual basis and confirmed that she would arrange the check as soon as possible. Water temperature records demonstrate some temperatures (13 in total) as high as 54.50C. Water temperatures in excess of 430C give a risk of scalds to residents. The manager said that a risk assessment has been completed for all temperatures that are regularly recorded in excess of 430C and “caution hot water” stickers are in place over these sinks. These risk assessments were not shown to the inspector but have since been requested for review. Staff were seen encouraging a resident to get up from her seat as she had spilled her cup of tea. When the resident would not rise staff used an inappropriate moving and handling technique to move the resident from her seat. This could have caused injury to the staff and the resident. All other records seen were satisfactory. A requirement was made at the last inspection regarding prevention of burns from unprotected radiators. The deputy manager confirmed that all radiators are now covered and do not present a risk of accident to residents. The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 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 The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 28 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 OP12 Regulation 16 Requirement The registered person must ensure that there are organised activities that meet the residents’ social, cultural and interest needs. 23 The registered provider and manager must ensure that all parts of the Home are in good decorative order and well maintained. The Registered Manager must ensure that all staff receive regular updates regarding mandatory training. Evidence must be available to demonstrate that staff have achieved competence at all elements of induction training. The Manager must ensure that all issues that relate to the health and safety of staff and service users detailed in the main body of this report are addressed as a matter of priority i.e. fire doors must not be wedged open, equipment must DS0000004259.V323088.R02.S.doc Timescale for action 21/04/07 2 OP19 13 10/05/07 3 OP30 13 19 10/05/07 4 OP38 23 21/04/07 The Woodlands Version 5.2 Page 29 be serviced and checked in line with requirements, staff must use appropriate moving and handling techniques when assisting residents to manoeuvre. 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 OP12 Good Practice Recommendations More detailed information should be recorded to demonstrate the activities undertaken on a daily basis and who has participated. The registered person should ensure that there is a staff training and programme that meets the National Training Organisation workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of residents. Copies of the risk assessments undertaken regarding the risk of scalds from hot water should be forwarded to the Commission for Social Care Inspection. 2 OP30 3 OP38 The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 The Woodlands DS0000004259.V323088.R02.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!