Inspection on 22/01/08 for The Woodlands

This inspection was carried out on 22nd January 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

The Woodlands 14/02/07

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 Unannounced Inspection 22nd January 2008 09:15 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.V358418.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. The Woodlands DS0000004259.V358418.R01.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 F/P 01527 852815 woodlands-home@hotmail.co.uk 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.V358418.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2007 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 £384 - £600 per week. Additional charges are made for chiropody, hairdressing, newspapers, magazines and toiletries. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is upon outcomes for people who live in the home and obtaining their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The following information in this report are the findings of an unannounced inspection visit that took place on Tuesday 22 January 2008. Eighteen people were living at The Woodlands at the time of the visit. The short observational framework for inspection was completed. This involved spending one and a quarter hours observing the care being given to a small group of people. The care file of one of these residents was reviewed and a comparison made with the observations and the home’s records. One other resident was ‘case tracked’, this involves finding out about their experience of living in the care home by meeting with them, or observing them, talking to them and their families (where possible). Information held in care files was reviewed and discussions held regarding their care with staff and relatives. The environment in which they live is looked at and discussions about the Home are held with staff on duty. Staff training records are reviewed to ensure training is provided to meet resident’s needs. Documentation regarding staffing, health and safety, medication and complaints are also reviewed. During the inspection, the manager was on duty along with the three care assistants, a domestic, handyman and the cook. The registered owner attended for part of the inspection. The inspection process consisted of a review of policies and procedures, discussions with the manager, staff, visitors and residents. Other records examined during this inspection included, care, staff recruitment, training, staff duty rotas, health and safety and medication records. Notification of incidents received by us from the Home and any other information received were also examined. Before this inspection took place the manager of the Home completed their “Annual Quality Assurance Assessment” (AQAA) and forwarded this information to the inspector. Information contained in the AQAA was used as part of the inspection process. The inspection process enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. The inspector was introduced to a majority of the people that live at The Woodlands and conversations were held with four people. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 6 The inspector wishes to thank the manager and staff for the hospitality on the day of inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. What the service does well: What has improved since the last inspection? Three of the four requirements made at the last inspection visit have been addressed and one partially addressed. At the last inspection there was no documentary evidence to demonstrate that regular activities take place, residents spoken to were unable to confirm that activities took place and there were no activities on the day of inspection. The The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 7 manager has developed a new form for each individual resident that records the activities that they participate in on a daily basis. Care files also contained information regarding residents past social and leisure interests, this enables staff to try to provide activities to meet the needs of individuals. During this inspection a member of staff was seen completing a hand massage, which some residents really enjoyed. Music was playing in the lounge and some residents enjoyed singing and clapping, whilst other residents read newspapers or chatted amongst themselves or to staff. An issue was identified at the last inspection regarding some of the décor in the Home, which was marked, and in need of attention. The lounge has since been re-decorated and the Home was in a reasonable state of repair during this inspection. This standard was therefore met during this inspection. Some health and safety issues were identified during the last inspection. Fire doors were seen wedged open, hot water temperatures in resident areas were above the maximum safe temperature of 430C and portable electrical appliances had not been safety checked. Door guards have now been fitted to doors that need to be kept open. These automatically close the door if the fire alarm sounds, this therefore maintains the safety of residents whilst respecting their wish to keep the door open. Portable electrical appliances have been safety checked and risk assessments are in place regarding hot water temperatures. The requirement made regarding induction and mandatory training has been partially met. A new induction system has been introduced and all staff are undertaking this training. However, mandatory training had not been undertaken by newly employed staff and the training matrix demonstrated that some staff need update training. The manager gave her assurance that this will be undertaken as soon as possible and the training was arranged on the day of inspection. What they could do better: The manager and staff work hard to meet the needs of those under their care and were all open to comments regarding improvements that could be made. The manager was advised to obtain advice regarding the current methods of cleaning commodes and the location of the area in which these are cleaned. Advice regarding the methods used to store soiled linen before it is sluice washed should also be sought. The current method of placing the linen in a bucket may not be the best method available as this may present a risk of cross infection. A copy of any report provided by the external professional should be kept on the premises to demonstrate that the methods/location in use are the best available for this Home to maintain infection control standards. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 8 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.V358418.R01.S.doc Version 5.2 Page 9 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.V358418.R01.S.doc Version 5.2 Page 10 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 excellent People who are considering moving into the home benefit from having their care needs assessed so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care file of the resident most recently admitted to the Woodlands was reviewed. The manager conducted a pre-admission assessment on 11 July 2007, the placement was agreed and the person moved into the Woodlands on 12 July 2007. Standardised documentation is used during the pre-admission process. This documentation covers thirty-eight separate areas regarding daily life, social and care needs such as communication, sight, social skills, risk of falls, personal hygiene etc. Pre-admission information is important as it gives staff the necessary information to write a comprehensive plan of care to support meeting the needs of people to be admitted to the home. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 11 The pre-admission assessment for the resident whose care file was reviewed contained sufficient information to enable staff to meet this persons needs. An activities of daily living plan and care plans were then developed on the day of admission. The manager confirmed that it is usual practice for her to conduct preadmission assessments. Once all information has been gathered, including information from the care management team if applicable, a decision is made as to whether the Woodlands will be able to meet the potential resident’s needs. A letter is then sent out inviting the person to stay at the Home free of charge for a night or a weekend. This will help them make the decision as to whether the home will be able to meet their needs. Prospective residents and their relatives are given the service user guide and the Home’s brochure. This, along with the stay or visit to the Home, gives them all of the necessary information to enable them to make a decision whether they wish to move into the Woodlands. The family member of the resident whose care file was reviewed spoke to the inspector and confirmed that her husband was seen by the manager before being admitted to the home. She had looked around the Home and spoken to staff and had been given the Service User’s Guide and details of the website to download copies of previous inspection reports regarding the Woodlands. It was noted that the manager was extremely helpful and the relative was encouraged to visit at any time to have a look around before a decision for her husband to move in was made. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 12 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 Care plans set out the needs of residents and details of external professionals required to assist in meeting health and personal care needs. Procedures are in place to ensure the safe administration, recording and storage of medication. People’s rights to privacy and dignity are upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two people were identified for case tracking and their care plans were read during the inspection. The care file of the most recently admitted resident and the care file of someone who has been living at The Woodlands since 2000. Care plans seen were based on information gained during the pre-admission process, including social services care plan information if applicable. Monthly reviews take place and where needs change care plans are updated with new information. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 13 An activities of daily living plan is put in place on the day of admission to the Woodlands. Information is recorded regarding communication, eating, personal hygiene, sleeping, mobilising, dressing and leisure as well as other areas of daily living. Documentary evidence seen demonstrated that these plans are reviewed a few days following admission and then two or three times a year. The information gives staff guidance regarding the needs and abilities of those under their care. They also identify the changing dependency needs of residents and the need for increased numbers of staff to provide assistance. A social care assessment is completed on the day of admission. Information regarding family, visitors, pets, previous occupation and previous hobbies were recorded as well as details regarding favourite T.V. programme, newspaper etc. This information can then be used to plan social and leisure activities for individual residents. Care plans contained relevant, up to date information and were available for the identified needs of each person. The comprehensive information recorded gives staff the information needed to make sure the person’s needs are met safely and appropriately. They record areas where assistance is need, where encouragement or prompting is needed and actions that the resident is able to complete unaided. When assistance is required details of how staff should assist are recorded. The key worker system is in place at the Home and staff spoken to were aware of their roles and responsibilities regarding key working. A diary of activities undertaken by each resident is recorded in their file. One seen recorded that the person read the newspaper most days and went out with or was visited by his wife. The manager confirmed that other activities take place regularly but residents are free to choose something different or decline to take part. Daily entries, although repetitive and not very detailed on each occasion, recorded the action that staff have taken to meet care plan goals. There was limited evidence in daily entries that staff were checking on residents on an hourly basis throughout the night. However, a separate form has been developed to detail whether the resident was awake or asleep at hourly checks, whether any staff intervention was needed and the clothing that the resident is wearing when they get up in the morning. This form is kept separately from care plans. Records in care files confirmed that people have access to optical, hearing, chiropody, District nurse and Community Psychiatric Nursing services. There was evidenced that Doctors visits are requested as required and short-term care plans had been developed when new health care needs identified. During conversation with the manager it was noted that staff attend hospital appointments with residents if this is the wish of the family. This is good The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 14 practice as it puts the resident at ease and information gained at the hospital appointment can be recorded in the resident’s care file. Risk assessments for mobility, nutrition and the risk of developing pressure ulcers were seen for all residents involved in the case tracking process. Appropriate care plans were available where a risk had been identified stating clearly the needs required and actions to be taken by staff. Some of the positive comments made by relatives regarding the care that their loved ones received are detailed below: “I feel that … is safe and well cared for” “She has seen a GP recently, had a blood test and her eyes checked, all of her needs are met”. “if I want to see the care records I just ask, it is all very open here” “As far as I am aware all of … care and social needs are met” A conversation was held with the most recently admitted resident in his bedroom, his wife was also in attendance. It was noted that the relative came to look around the Home before the pre-admission assessment took place. The manager apparently gave lots of information about the Home and was approachable and friendly. The resident spoken to was smartly dressed and his hair brushed neatly. He said that he likes the food, there is a small choice every day and there is always plenty to eat. He confirmed that he liked the staff, they are all nice. It was noted that since admission he had settled extremely well into the Home and was able to continue his leisure activities of reading the Birmingham Post and doing crossword puzzles. The person spoken to said that he liked to watch the sport on the television. It was noted that staff always respect privacy and never enter the bedroom without knocking and waiting to be asked in. The relative stated that staff are all very hard working, kind and friendly. She is always made to feel welcome and staff keep her updated regarding her husband’s health and general wellbeing. The manager has an open door policy and you are able to speak to her at any time. It was noted that they were very pleased that the resident had moved to live at The Woodlands. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 15 Medication systems, practices, and the medication records for the two residents being case tracked were reviewed. Systems are in place for the safe administration, storage and recording of medication on the premises. Medication is received every twenty-eight days, unused medication is returned at the end of the twenty-eight day cycle and records were available to demonstrate that this is done in an appropriate manner. Systems are in place to check medicines prescribed against those received from the local pharmacy. This ensures any discrepancies are sorted out immediately. Medication records reviewed were up to date and in good order, the stock of medication available balanced with that records held. The morning medication round was observed. The staff member concerned distributed medication to residents on an individual basis from a dedicated medication trolley, which was taken around the Home during the medication round. Policies and procedures are in place regarding medication systems and practices and these have been reviewed recently. The current systems in place regarding medication management protect residents from risk of harm and ensure that they receive the required medication on a timely basis each day. Observations during the inspection visit found that people living in the home looked well cared for, clean, dressed in appropriate clothing and their hair had been combed and nails trimmed. Staff frequently engaged with residents in the lounge, chatting, comforting and completing activities. Those resident’s observed appeared to be at ease in their surroundings and were free to go to any communal area that they wished. Staff were kind, caring and attentive to individual needs. The atmosphere at the Home was relaxed and friendly Staff were seen to treat people with dignity and respect. Personal care needs were carried out behind closed doors therefore respecting people’s privacy and dignity. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 16 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 good The lifestyle people experience in the home matches their preferences; they are supported to maintain their independence and interests, which enhances their quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A discussion was held with the manager, residents and their relatives where possible to try and identify whether the range of activities provided at the Home is suited to the wants and needs of those that live there. There was no activity programme on display. The manager confirmed that the activity programme is used as a guide for staff regarding the type of activities that could take place. Staff offer residents an activity each day and this is changed if residents do not wish to participate. On the day of inspection music was playing in one of the lounges and a majority of residents present were thoroughly enjoying singing and clapping to the songs. The manager was observed asking residents whether they wanted the television or music on and what type of music they wanted to listen to. A member of staff gave a hand massage to some of the residents in the lounge. Staff were seen sitting and chatting to residents, particularly if a resident became distressed. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 17 Any activity undertaken by a resident is recorded in their care file. The two residents case tracked had participated in activities such as reading the newspaper, watching a film, armchair activities, receiving visitors or chatting to staff. The manager confirmed that other activities take place such as bingo, reading magazines, exercise to music providing light physical exercise, watching films. This was confirmed in the activity records held in another care file seen. One visitor spoken to confirmed that activities take place on a regular basis. He said that his wife enjoys watching but likes to wander around and help in the kitchen drying dishes etc. It was noted that notable events such as Christmas, Birthdays and Easter are celebrated and parties are held. A general denominations church service is held on the second Thursday of each month for those residents who wish to continue with their religious beliefs. Details of residents past hobbies and interests and present interests are recorded in their care file to enable activities provided to meet their needs. The minutes of the last Residents/relatives meeting held discussed activities and some suggestions were made by residents. The manager confirmed that activities suggested had been implemented where possible. The home has an open visiting policy. Visitors are welcome throughout the day so that they can maintain involvement in the care of their loved one. This was confirmed by two relatives spoken to who said that they are able to visit at any time, are always offered refreshments and made to feel welcome. Staff also update them regarding the changing needs of their relative. People choose to see their visitors in the lounge or in their own private accommodation. Visitors said that they liked some private time with their relatives to chat and read the newspaper and therefore preferred to go into their room. Visitors also said that they can visit at meal times and can have a meal with their loved one if they wish. Evidence in care files demonstrated that residents are given choices regarding daily life at the Home. Residents are encouraged to maintain a level of independence which they are capable of, for example choosing what time to get up in the morning, what clothes to wear, where and when to eat their breakfast. Residents are able to choose whether they prefer personal care assistance from a male or female carer and are able to choose an individual staff member, which they have a good rapport with to provide assistance when they are on duty. Residents were seen freely wandering around the building and appeared to be at ease in their surroundings. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 18 The meals at the Home were discussed with some residents, all confirmed that the food is good and there is plenty of it. It was noted that there are snacks available if you want and bowls of fresh fruit were seen for people to help themselves. Residents commented that “the food is good, you get a little choice every day, there is always plenty to eat”. “the food is good and there is plenty of it, you get snacks as well”. A diary is used to record what meals are served daily. From information seen it was noted that residents have a choice of cereal and/or toast for breakfast. A choice of two hot lunchtime meals. A choice of evening meal i.e. sandwiches, and a supper. Records seen showed that a range of supper foods were available such as sandwiches, soup, scone and butter, rice pudding and jam or crumpets. Although a choice of two meals is offered on a daily basis residents are able to have an alternative if they wish. Records confirmed this and demonstrated that occasionally residents were having beans or tomatoes on toast for breakfast. The manager said that residents are also able to have a full English breakfast if they wish. Some residents who chose to stay in the lounge were observed eating their breakfast. The cook brought cereal on a trolley and residents chose what they wanted. Later toast and a cup of tea was offered to residents. All appeared to be enjoying their meal. One resident who required assistance eating was observed eating the main lunchtime meal in the lounge. Staff were assisting this resident in a patient, discreet manner. Again the resident appeared to be enjoying her meal. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 19 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 good Complaints procedures are available and any complaints received would be taken seriously by the home. Policies and procedures are in place to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy which is on display and available in the terms and conditions of residency and the Service User’s guide. The manager said that she has an open door policy and welcomes any comments, these are addressed immediately and therefore complaints are not made. Neither the Commission for Social Care Inspection nor the Home have received any complaints. Visitors spoken with said that they would speak to the manager if they had any worries and they felt sure that she would sort them out. One relative spoken to said “I have no concerns but if I did I would speak to the manager, she would sort it out for me”. Staff spoken with were aware of the complaint procedure and confirmed the action they would take if they received a complaint Policies regarding adult protection and “whistle bowing” are available in the home. These policies are freely available to staff. Staff have attended training on how to recognise abuse and the protection of vulnerable adults. Discussions with staff demonstrated that they are aware of their role and The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 20 responsibility in reporting any suspicion of, or actual harm to residents. They were aware of the Home’s procedures and the relevant authorities to report allegations of abuse to for further investigation. The manager has obtained further information regarding adult protection and this is available for staff. A copy of our “rights, risks and restraint” booklet was available and staff are encouraged to update regarding best practice. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 21 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 The standard of the environment within the home is generally well maintained providing a homely place to live. This ensures their comfort and wellbeing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Woodlands is not a purpose built Care Home but has been adapted to meet the needs of eighteen elderly people who may suffer from a dementia type illness. At the time of inspection the Home was full. A brief tour of the premises was undertaken to evidence whether the Home is well maintained and has the fixtures and fittings to meet the needs of those that live there. Communal areas such as lounges and dining rooms, the bedrooms of those residents being case tracked plus two others and the laundry room were all viewed. The Home was fresh and clean and no unpleasant odours were noted. Bedrooms seen had been personalised with The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 22 pictures and ornaments. Rooms were comfortable and homely. One of the bedrooms seen was shared by two residents. Appropriate curtaining was in place to maintain privacy and dignity when needed. Another room seen was a very large single room. The occupant had brought her own settee so that she can see guests comfortably in her room. Communal areas consist of a lounge, a dining room with conservatory extension with comfortable seating. All of these areas were domestic in style. Residents were seen wandering freely around the Home, chatting to staff and other residents. Furnishings and fittings were in a reasonable state of repair and provided a homely, comfortable environment. The laundry in the home is small, but sufficient to meet the needs of the residents and the size of the home. The room was seen to be clean but there was a large backlog of items waiting to be laundered and some items waiting to be put back into resident’s rooms. Items of laundry requiring a sluice wash are currently left in a bucket in the corner of the room until the washing machine is free and then washed. A discussion was held regarding other methods of cleaning soiled laundry which reduces the amount of times staff have to handle this laundry which therefore reduces the risk of cross infection. The manager was advised to get further information regarding this and consider using alternative methods. A discussion was held regarding the cleaning of commodes. The manager said that bedrooms are ensuite and therefore commodes are not used on a very regular basis, although they may be used each day. The manager was requested to get further advice regarding the current methods of cleaning commodes to ensure that it is the best process available within the current environment. Equipment to assist residents maintain mobility and independent access around the home is provided. Grab rails are positioned throughout the home. Walking aids were seen and a shaft lift is available to access the accommodation on the first floor. Risk assessments were in place for those residents whose bedrooms are on the first floor and who may be at risk of injuring themselves when walking down the stairs unaided. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 23 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 good Robust recruitment systems are in place to ensure that suitable staff are employed. Sufficient numbers of trained staff are on duty to meet the health and personal care needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evidenced from duty rotas and the numbers and skill mix of staff on duty at the time of inspection that there were sufficient staff to meet the needs of residents accommodated in the home. The manager confirmed that the usual care staffing complement for the home is: 8am – 9pm 9pm – 8am 3 care staff 2 care staff A cook, kitchen assistant, maintenance person and domestic staff are also employed, the cook also works shifts as a care assistant on some occasions. During discussions with the manager it was noted that staff are able to alter their shift pattern for their convenience if they have other caring The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 24 responsibilities. The duty rota demonstrates this and shows that multiple start and finish times are in operation. The manager also confirmed that they provide assistance with transport if required and staff are able to eat a meal when on duty provided by the Home. Staff turnover at The Woodlands is low. It was noted at the last inspection that duty rotas did not clearly demonstrate the number and job role of staff on duty on a daily basis. Duty rotas have now been changed and record the full name of the staff member and their job role. The manager’s hours are recorded, the manager works on a supernumerary basis but does provide hands on care if needed. The manager confirmed that they do not use agency staff at this Home. Any vacant shifts are covered by staff who work at the Home and the four “bank” staff employed to work occasional shifts. From observations on the day of inspection it was evident that there are sufficient staff on duty to meet resident’s personal care needs. Staff also spent time sitting with residents chatting and comforting them when necessary. Staff spend time each day completing laundry duties but the manager confirmed that the needs of the residents are always priority. As the Home employs catering, cleaning and maintenance staff, care staff do not spend undue lengths of time undertaking non-caring duties. Both visitors to the Home and residents made positive comments about the staff working at the Woodlands, “staff respect your privacy and knock on doors before entering”, “staff are all very friendly and kind”, “staff keep you informed with everything that goes on”. A member of staff spoken to said that staff “work well as a team”, “have all of the equipment needed to do their job” and confirmed that the manager is “approachable and gives you support when you need it”. The manager and owner provide the on call advice on a daily basis. The manager confirmed that if for any reason she is not able to be contacted a senior carer will be available. Currently twelve care staff are employed at the Woodlands, eight of these staff have a National Vocational Qualification (NVQ) at Level 2 in Care. The remaining staff are enrolled to start NVQ training shortly. Providing good quality training goes some way to ensure that staff have the necessary knowledge and skills to look after those under their care. Catering and domestic staff have also completed NVQ training in their relevant field of employment. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 25 Recruitment procedures and practices were discussed with the manager and three staff personnel files were examined. Files contained evidence that recruitment procedures are robust and sufficient information is obtained before staff are employed to ensure that residents are safeguarded. Two written references, Criminal Record Bureau (CRB), Protection of Vulnerable Adult (PoVA) and curriculum vitae’s are obtained before staff commence employment in the home. Since the last inspection new induction documentation has been purchased and is in use. This is linked to the Skills for Care induction programme. Staff watch DVDs, complete worksheets and have multi choice examinations before being deemed competent. They then complete a four-week induction programme. The manager confirmed that all staff have or are in the process of completing this induction training. Training records demonstrate that a majority of staff are up to date with training. Newly employed staff require training regarding moving and handling, food hygiene and first aid. The manager confirmed that this will be undertaken shortly. There is a “training room” in the Home that has reference books for staff to use if needed. There is a television and DVD player and staff complete DVD based training in this room. The manager confirmed that until external mandatory training can be arranged for these staff they will watch a DVD to guide them regarding best practice. The manager was trying to arrange training during the inspection visit. A training matrix is available which shows that a majority of staff have undertaken training in first aid, dementia care, moving and handling, food hygiene and fire safety. The AQAA provided by the Home before the inspection records that “Staff training is paramount, all staff undergo rigorous training inclusive of the mandatory basics we access and implement additional courses. A large matrix in the main office (which was on display on the day of inspection) indicates with a ‘gold star’ at which level of their training they have reached. A ‘Goal’ incentive is offered with a highly visible approach to success, child care and transport costs are often provided, current reading materials are visibly on hand as is the internet provided for research”. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 26 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): Quality in this outcome area is good The home is managed by an experienced and competent person who supports the needs of staff and residents. The quality of the service provided is maintained to a high level and is run in the best interests of those people that live at the Woodlands. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has worked at the home for over fourteen years and has the necessary experience and training required to undertake the role. The manager is enthusiastic and dedicated to meet the needs of residents in a homely and caring manner. The Home owners also take an active role in the running of the Home. One of the owners was present during the inspection and was knowledgeable about the residents, the manager also has an in-depth knowledge of the care needs of those that live at the Woodlands. The manager undertakes update training as necessary. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 27 Visitors to the Home spoken to during the inspection had every confidence in the manager. They commented that she was “approachable and helpful” “would sort out any problems for you” and that the Home was very “open, you just ask and they tell you everything you need to know”. During the inspection the manager was seen to have a good relationship with those under her care, the staff and visitors to the Home. The home has comprehensive quality assurance systems in place to assess the services provided. Quality assurance systems are based upon the national minimum standards and requirements. The Home owner audits all standards on a six monthly basis. The manager regularly audits practices such as care planning, staff files, medication risk assessments, induction and training, fire and maintenance. Policies and procedures to be followed by staff that ensure the safety of people living in the in the home have recently been updated. Satisfaction surveys are undertaken on a regular basis. The manager is devising new surveys to send to residents and their relatives. These are due to be sent out shortly. Residents/relatives meetings are held and minutes are taken. There is no action plan to demonstrate that any issues or requests made have been acted upon. However the manager was able to discuss the action taken from the last meeting. The manager agreed to write a few sentences to confirm the action that they take following each meeting. Regular staff meeting are held, minutes for the most recent meeting were examined and show that the staff are encouraged to participate in these meetings. The Home do not hold any funds on behalf of residents. Any expenditure for items such as private chiropody, hairdressing, newspapers and magazines are recorded and an invoice sent out to family members/advocates on a quarterly basis. Copies of receipts of expenditure are kept in the office and are available for examination on request. Invoices contain itemised details of expenditure. Records seen were suitably maintained. A sample of records were examined to assess the home’s systems for maintaining equipment and services. These show that the required safety checks have been undertaken. Records regarding lift and hoist servicing, portable appliances, Landlord’s Gas safety, employers liability insurance and the disposal of waste contract were reviewed. Lift and hoist servicing was due and the manager booked this while the inspector was in the office. Fire safety management includes regular testing of fire alarms, emergency lighting, staff training and fire drills. Records were in good order and up-to-date. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 28 A food inspection was undertaken by the Environmental Health Department in November 2007. The Home achieved the Silver Award. No issues for action were given. The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 29 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 4 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 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.V358418.R01.S.doc Version 5.2 Page 30 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. 3. Standard OP30 Regulation 13 19 Requirement The Registered Manager must ensure that all staff receive regular updates regarding mandatory training. Timescale for action 16/03/08 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 OP26 Good Practice Recommendations Further advice should be sought from an infection control specialist regarding the current methods of cleaning commodes and storage of soiled laundry waiting to be sluice washed. Consideration should be given to developing an action plan following residents meetings. This documentation demonstrates the action taken to address resident’s requests during these meetings. 2 OP33 The Woodlands DS0000004259.V358418.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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.V358418.R01.S.doc Version 5.2 Page 32 - 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. 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