Inspection on 28/11/06 for Withy Grove Care Home

This inspection was carried out on 28th November 2006.

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

The inspector 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

Withy Grove Care Home 29/09/08

Withy Grove Care Home 29/07/08

Withy Grove Care Home 08/08/07

Withy Grove Care Home 26/05/06

Withy Grove Care Home 22/11/05

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

CARE HOMES FOR OLDER PEOPLE Withy Grove Care Home Withy Grove House Off Poplar Grove Bamber Bridge Preston Lancashire PR5 6RE Lead Inspector Mrs Marie Dickinson Unannounced Inspection 10:30 28th November & 1 December 2006 st 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 Withy Grove Care Home DS0000065186.V318034.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. Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Withy Grove Care Home Address Withy Grove House Off Poplar Grove Bamber Bridge Preston Lancashire PR5 6RE 01772 337105 01772 620158 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) www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mrs Janet Elaine Plummer Care Home 54 Category(ies) of Dementia (24), Old age, not falling within any registration, with number other category (30) of places Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 54 service users to include: Up to 24 service users in the category of DE - (Dementia). Up to 30 service users in the category of OP - (Old Age, not falling within any other category). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 26th May 2006 2. 3. Date of last inspection Brief Description of the Service: Withy Grove House is a residential care home providing 24-hour personal care and accommodation for 30 older people who have care needs and 24 older people who have care needs associated with dementia. The proprietors of Withy Grove House are Ashbourne (Eton) Limited. Withy Grove House is a converted Manor House, which is set in its own landscaped gardens adjacent to parkland. The home is in a predominantly residential area, but within easy walking distance of Bamber Bridge centre. Bus and train services can be accessed to larger towns, such as Preston, Chorley and Blackburn. Bedroom accommodation is on the ground and first floors. All bedrooms are used for single accommodation and 29 have en-suite facilities. There is a passenger lift. Accessible toilets and bathrooms are located on both floors near to bedroom and living rooms. There are sitting and dining areas sited on both floors and across the car park from the home is a private lawn area where residents are able to enjoy activities, weather permitting. Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was conducted in respect of Withy Grove on the 28th November and 1st December 2006. The inspection involved getting information from staff records, care records and policies and procedures. It also involved talking to residents, staff on duty, the manager and visitors, and included a tour of the premises. Areas that needed to improve from the previous inspection were looked at for progress made. The home was assessed against the National Minimum Standards for Older People. What the service does well: People referred to the home benefit from having their needs assessed to make sure they will be given the right help. Important information needed to support them in every day living was recorded and used to plan the care required. A relative was impressed at the way this was carried out. Residents living in the home benefited the support of a named worker referred to as a Key worker who took responsibility to make sure care needs for individuals was personalised. Resident’s said they were happy with their carers and thought they were ‘good’. Healthcare needs were monitored and staff worked with visiting medical professionals for the benefit of residents. Advice was sought where needed, such as for pressure care and mental health care. Visitors who sent written comments for the inspection said they were made welcome to the home and could make a visit in private if they wished. One comment referred to ‘Excellent care given to the residents’. Relatives also said they were always kept informed of any changes in their relatives care needs. There were no rules in the home and routine was personal to each resident. Arrangements were made for representatives from different religious beliefs to visit residents as they wished. Residents had a good opinion of staff in the home and described them as ‘good girls’ and ‘very very good’. The training provided for staff was good. Staff on duty during inspection showed they had a good knowledge in understanding the needs of older people. They were supervised in their work. Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 6 Systems were in place to approach residents/relatives to give their view on the quality of services and facilities in the home. Small amounts of money held on behalf of residents were managed well. What has improved since the last inspection? To make sure residents receive the right care, assessment of needs had been kept under review. By assessing needs regularly, changes in individual circumstances were dealt with promptly and essential support provided by staff. Monitoring of resident’s healthcare had improved, and advice and treatment prescribed for residents was followed in a timely manner. Continence care for residents had improved. Nutritional needs of residents are monitored. The residents accommodated in the dementia unit are offered a varied selection of food and improvements have been made in how it is served. To help prevent injury and maintain the dignity of residents in the dementia unit residents had suitable footwear on. People visiting the home said they feel comfortable speaking to staff. To make sure residents are protected from records sent to the Commission show allegations of abuse is responded to promptly. Accommodation and facilities had improved. This included general maintenance of the driveway, safer access to the garden areas by removing built up debris and the gardens maintained to a better standard. Improvements required in the dementia unit to improve the general standard of accommodation were ongoing. To help residents find their rooms name plates were fitted and other means of recognition used. Some bedrooms had been decorated and suitable furniture provided. Lighting in the dementia unit was improved and the corridors decorated giving a good atmosphere for residents. The heating was also controlled better and guidance on maintaining satisfactory levels such as during a heat wave was available for reference. The home was generally tidy and to keep the home from smelling unpleasant, cleaning arrangements had been improved with sufficient staff employed for this purpose. Designated smoking areas are provided so that non smokers comfort is maintained. Laundry facilities were clean and organised with better care given to resident’s personal clothing and footwear. Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 7 Training of staff includes first aid and written information received at the Commission show twenty staff to have completed this. The manager had made considerable progress to improve all standards’. There was evidence better partnerships between the members of the home and management structure has improved communication, allowing change processes to be implemented. Staff have regular supervision and as good practice are given a return to work interview following absences due to sickness. What they could do better: A service user guide must be made available for people wanting to read information about the home. As a matter of courteousness, residents should always be kept informed of any changes in the amount they are charged for their stay at the home. To make sure residents are cared for according to their needs, an effort should be made to bring all care plans up to the new standard some resident’s benefit. Staff need to recognise symptoms to administer ‘when required’ medication prescribed by doctors particularly for people with dementia. More detail as to circumstances or symptoms it would be given should be recorded. Residents right to enjoy privacy should be respected. The complaints procedure must be promoted better and displayed clearer. Residents must be provided with a sufficient range of suitable activities that would meet their needs and expectations. To make sure residents are protected from abusive situations between residents, management must take necessary precautions to avoid such incidents by protecting their privacy of space. This includes consideration to disguise the adjoining doors in bedrooms to minimise confusion for residents in the dementia unit. The institutional labelling of drawers such as ‘vests’ should not be done unless it is to help people needing this level of support. Emergency pull cords should not be removed from bedrooms. Some bedroom floor coverings required replacing and kept from smelling unpleasant. The kitchen required some general maintenance such as repairs to tiling and high cleaning dealt with properly. Sluice rooms could improve in cleanliness and staff must always have sufficient protective clothing. Sufficient staff must be employed to make sure that resident’s care is given to a satisfactory standard and the numbers of staff on duty be effectively Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 8 maintained. This is a concern of a relatives who gave written several comments about standards in the home and was observed during inspection particularly around mealtimes. Better care must be taken when recruiting staff to make sure the right documentation has been completed. Staff welfare should also be considered. The views of relatives must be positively considered to make sure residents are given better care. 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. Withy Grove Care Home DS0000065186.V318034.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 Withy Grove Care Home DS0000065186.V318034.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): 1,2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had access to information about the services and facilities available to help them make a decision to stay at the home, however this requires formalising. Every person had a written contract/terms of conditions of residency. Assessments of people wanting to live in the home contained enough information to plan how care needs were to be met. EVIDENCE: The statement of purpose was available in the office, however the service user guide was not yet completed for the home. The manager said it had been changed to show the change of ownership and was being finalised. There was Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 11 a brochure outlining the services breifly. It was simple to read and contained some useful information. People living at the home gave a general opinion that this information was not very important to them as their family had helped to choose the home and they had a trial stay. Since the last inspection there had been a number of admissions. Records made during the admission process showed how the home managed this. The pre-admission assessment format was thorough and covered all aspects of personal, health and social care needs. In most instances both social care assessment and a homes assessment was completed. These contained sufficient details essential to plan the right care for individuals. Relatives visiting said they were ‘very impressed with the standard of assessment and had appreciated the visit by the manager to see their brother before he was admitted. They considered the line of questions asked to be ‘very good and appropriate.’ Residents had contracts outlining the terms and conditions of residency in the home. Those residents who were interviewed were unaware of the charges they paid to stay at the home. the general feeling was residents did not want ‘to bother with things like that’, as their family dealt with this. How residents are informed of any increase in costs however needs to improve. The manager said that the organisation makes sure residents are informed in advance of new charges. How costs were paid was sorted out when people were admitted. Withy Grove Care Home DS0000065186.V318034.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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans written for residents helped staff to provide the right personal care for residents. Healthcare was monitored. Residents were satisfied their care needs were met and they considered staff were respectful to them. Medication was managed safely. EVIDENCE: Each resident had a plan of care based on an assessment of needs. Some of these provided sufficient detail about all aspects of daily living that included preferred daily living routines and the assistance each resident required with personal care. For example a plan of care for a resident with Alzheimer’s Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 13 disease detailed in a way how staff must support them personally in everyday living and safely maintain independence and dignity. Not all care plans however had been completed onto the new documentation. The manager said staff training includes writing care plans. Overall the standard was good. The plans were reviewed regularly and where changes in care was needed this was recorded. Relevant professional advice and relatives views were sought. Risk assessments had been completed and were used as guidance for staff to help care for residents safely. Records showed how care was provided on a daily basis and residents benefited the support of a named worker to help them with more personal care. Health care needs were generally met. Mental health care was being monitored and needs was identified. Staff were directed to follow best practice when managing residents with dementia who for example became agitated. Relatives attending a care plan review were complementary regarding ‘how the staff have got to know him’ and were amazed at the detail recorded. ‘His need for privacy of personal space and his liking of classical music is spot on.’ Better communication between management, medical professionals and staff meant that resident’s general healthcare had improved. Important issues such as weight monitoring were dealt with properly and when food intake was poor and difficulty with maintaining good nutrition, resident’s doctors had prescribed supplementary foods. Records show that people did access medical professionals such as district nurse and doctors. Continence management had improved. The rights of residents to be treated with dignity and respect was included in staff training. Rresidents spoken to generally felt the staff respected their right to privacy and made complimentary remarks about the staff. For instance ‘They are good’ and responses from residents sent to the Commission show they considered they received care and support, and received the medical support they needed at the home. Comments from relatives, however were varied. Respect for residents is not as it should be with issues around privacy. The home operated a monitored dosage system for the administration of medication. Information received at the Commission showed a number of staff had been trained in medication procedures. Records showed the receipt, administration and disposal of medication. Medication given as when necessary requires more detail as to when this would be given, particularly when the medication perscribed is for people with dementia. Resident’s doctors approved homely remedies for individual residents. Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 14 Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home did not provide residents with a sufficient range of suitable activities that would meet their needs and expectations. Visiting arrangements were good. Residents were offered a balanced and varied selection of food. EVIDENCE: The residents’ preferences in respect of choice in relation to routines of daily living was recorded in care plans for example times for getting up and going to bed. Residents confirmed they pleased themselves. A record of residents’ interests and preferences was also written into care plans. Although an activities organiser planned and presented activities and arranged outings, this still requires some development work. Comments from Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 16 residents confirmed they need to improve and focus more on what they wanted. As one resident pointed out ‘they are long days’. The notice board showed what events were planned, and the coming Christmas activities had been discussed at the residents meetings. Staff were observed taking a couple of residents out for a walk and corridors in the dementia unit had been themed for residents. One relative commented ‘however activities to stimulate residents; ‘a quiet music corner, nostalgia evenings, organ recitals might help’. Comments from residents and relatives showed visiting arrangements to be satisfactory. They all felt they could see their relative in private. A notice had been placed at the front door to tell visitors to ring the bell and alert staff of their presence. The residents made varied comments about the food. The menus had been changed. One resident said “the food is ok, there is a choice of meals.’ Menus received at the Commission prior to inspection showed a varied diet was provided. Records were kept of meals served. The provision of meals in the dementia unit had improved. Very dependent residents had been sat in one dining room enabling staff to be present and supervise or feed people. Staff however were observed to be busy serving and not always readily available to provide suitable assistance to residents. See under section ‘staffing’. A menu board was displayed. Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives/visitors had access to a complaints procedure. Complaints were dealt with properly. Staff were trained in Adult Protection however the management must take a more responsible role in prevention of abusive situations. EVIDENCE: A copy of the complaints procedure was displayed in the home, however only part of the information needed was visible. How to make a complaint was in the statement of purpose. The procedure gave directions on whom to make a complaint to and the timescales for the process. The manager said all documentation was changing to Southern Cross and most had been changed. The home had a recording system in place. One concerned relative had approached the Commission since the last inspection. Records showed this had been dealt with satisfactorily and a copy of the outcome was available to see. Comments reveived at the Commission showed relatives knew how to make a complaint . Residents equally said they knew how to complain. One resident thought this didn’t make much difference but other comments included ‘why Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 18 should I complain?, and ‘whats the point, I’m here aren’t I’. Another resident said she would tell the staff or the manager if she had any problems. Her daughter visited and always asks how she is. There had been one referral to the Adult Protection Team involving two residents which was dealt with correctly. Daily records and notifications received at the Commission that there had been a number of aggressive incidents because residents go in other peoples rooms. This was observed during inspection and discussed with the manager as it is a continuing concern. There are clear indications of aggressive reactions from residents who have their privacy of space intruded on. All staff were clear about protection issues and of their responsibility to report any suspician of abuse. The home had an appropriate internal procedure for staff to follow should they suspect or witness an incident of abuse. A whistle blowing policy was in place for the reference of staff. Adult protection training is covered in resident care training. Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment both internally and externally was adequate. There had been some general improvement to create a safe and attractive environment for residents living there. EVIDENCE: The home is a large adapted detached property set in its own grounds in a residential area of Bamber Bridge. The front of the home is next to a park Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 20 boundary and a number of large trees gives the home privacy. Car parking is to the front of the home. Residents can sit outside at the back of the home during warmer weather. The home is divided into two units for residential and dementia care. Access to these units is via a controlled lock; push button to access and key pad to leave. Following a tour of the premises, the following observations were made. The dementia unit was generally clean and odour free. Residents bedrooms had adjoining doors that were locked however the handle on the doors could potentially could potentially cause problems for people with dementia. This is because their understanding of handles on doors are to open and shut doors. One bedroom was particulary odorous. Furniture in some bedrooms had been replaced and there was a general overall improvement since the last inspection. The labelling of drawers such as ‘vests’ should not be done unless it is to help people needing this level of support. Not all bedrooms had emergency call leads attached. Some carpets required replacement and suitable floor coverings to the needs of individual people fitted. The decoration in the dmentia unit was bright and corridors were themed for residents. Peoples names were on on doors or other method of recognition such as a picture of a residents dog to help identify their own room more easily. The dining areas and lounges were pleasant and resident benefitted comfortable chairs in recesses off the corridors. Smoking areas was controlled. The residential unit still requires some upgrade in appearance but was adequate. The kitchen needed decorating and tiling on the walls required replacing. The manager said this was currently being dealt with. The cook said she felt she had enough equipment. The high cleaning particularly the ceiling must improve. The laundry was organised and clean. The staff responsible for cleaning said there had been an improvement with additional domestic staff. Laundry management was the responsibility of one staff employed specifically for this. Keeping the sluice facilities clean could improve. Temperature in the home was comfortable. The handyman and manager said the water temperatures were regularly monitored, and all the bathing facilities had controlled thermostats fitted for safety. Temperatures were set as given in guidance. Comments from a sample of the homes staff survey show staff generally do not feel the physical environment they work is comfortable. They also thought Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 21 there were times when protective clothing was not available. This must improve to control the spread of infection as there had been a number of contagious skin complaints and an outbreak of sickness reported to the Commission. Residents were pleased with their accommodation. Withy Grove Care Home DS0000065186.V318034.R01.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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The level of staffing was not satisfactory to make sure resident’s needs were satisfactorily met. Recruitment practices were adequate, however the high turnover of staff did not provide residents with a continuity of care. Residents had confidence in the staff working at the home. Essential training for all staff was provided. EVIDENCE: The manager had maintained a written staff rota and had sent copies to the Commission prior to inspection. These showed how the level of staffing was arranged for residents needs being met. Senior staff were on duty at all times. The numbers of staff employed however did not make sure the needs of the residents being fully met. Written comments from relatives/visitors thought there was insufficient staff and one relative commented ‘I have always thought the staffing numbers were not sufficient’. Observations made during inspection Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 23 found staffing levels did not always meet with residents needs for example during meals. A large number of staff had left their employment since the last inspection. Reasons for leaving were recorded on information received at the Commission and included absent from work, unsatisfactory, personal reasons, change of job and dissatisfaction with the job. An internal staff survey showed that the terms and conditions of work could improve. Staff work long hours. Sample responses from the homes staff survey show staff did not think there were sufficient staff on duty. They also felt they were not always supported in their work and felt undervalued. Residents however said they were ‘well looked after’ and that some of the staff were ‘very good’. One resident said ‘The staff are generally good, but they are always changing. You get used to one and then another appears.’ The use of agency staff was kept to a minimal. Several new employees staff records showed how recruitment practice was carried out. Employment checks for new employees had been completed. Protection Of Vulnerable Adult register checks were in place, however there were no Criminal Record Bureaux clearances to see. The manager said these were kept at head office. One recruitment reference received had not been signed and dated by the referee and two new employee recruited from oversees had no application details, contract or interview notes for reference. Other recruitment details show better care must be made when checking application forms such as dates of previous employment and reasons for leaving and gaps in employment explained. The manager said all staff received a contract of employment and equal opportunity monitoring was completed. New staff on duty confirmed they received induction training that covered policies and procedures and basic care. Information received at the Commission showed that the percentage of staff having accomplished NVQ level 2 and above was over 50 . Staff had a written training assessment and profile which showed other mandatory training had been provided. Information from the managerprior to inspection showed training had been planned for the year. This information also showed the number of staff with first aid had increased to 20. Further training planned included dementia, ‘o good lunch’, care plans, tissue viability, customer care, medication, activities for daily living, records and record keeping, all mandatory training and National Vocational Qualification in care. Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 24 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): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is qualified and registered at the Commission. Administration in the home was generally well managed. Guidance and support was given to staff by the management team and from the area manager of Southern Cross. Quality assurance monitoring was completed. Resident’s financial interests were protected. The health and safety of residents and staff was considered. EVIDENCE: Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 25 Since the last inspection the manager has been registered at the Commission She is a qualified nurse and has many years experience of working in and managing care services for older people. The registered providers, Southern Cross have an active role in the management of the home and visit once a month to oversee management performance, and give the manager supervision. The manager is also supported by a deputy manager, unit managers and senior carers. The manager was clear about her role and responsibilities, and has shown a positive commitment to improve all standards identifed as not met during the last inspection. Staff on duty during the inspection said they were confident in the manager and would approach her any time for advice. An internal staff survey did indicate there were some staff who thought management could improve particularly at organisational level. There was evidence of improved communication systems showing how the management team worked together to bring about change for the benefit of the residents. Residents and staff benefited from regular meetings, and meetings for residents relatives took place. The views of relatives must be considered when monitoring the service residents receive and action taken to improve the standards some staff work to. All responses received at the Commission from relatives showed they were informed by management of important matters affecting their relative. Residents who are able manage their own finances continue to do so. Small amounts of money are managed for residents wanting this service. Records were kept of transactions made on behalf of people. There was a set of policies and procedures, and according to written documentation sent to the Commission, these had been reviewed in line with current good practice and legislation. To make sure staff read and understand these documents they are included in staff meetings and supervision. Supervision was being given to staff on a regular basis, senior staff had responsibilities in this area. Staff said the supervision covered work issues and considered them useful. New staff benefited from induction training and their work supervision was ongoing. Return to work interviews after absences of sickness were completed. Written working procedures and training opportunities were available to support development of good care practice. All new staff members were receiving induction and essential training. This training included first aid. Fire safety procedures were evidenced as being given to staff and regular fire drills carried out. Information contained in the pre inspection questionnaire indicated that gas and electrical safety certificates were up to date. Water temperatures at source, and in bedrooms, had been regularly checked and were being Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 26 maintained close to temperature as required. The storage of cleaning products was satisfactory. Information was received at the Commission during the year giving details of significant events and occurrences. Withy Grove Care Home DS0000065186.V318034.R01.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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 2 17 X 18 2 2 3 X X 2 2 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 3 3 3 Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2 Standard OP1 OP12 Regulation 5(1) 16(2)(n) Requirement An up to date service user guide must be made available that is specific to Withy Grove. Activities should be made available for all residents to meet their individual needs in relation to promoting their wellbeing. 26/06/06 To make sure residents are protected management must take necessary precautions to avoid aggressive situations between residents. People’s views must be listened to when they request staff to respect the privacy of residents by keeping doors locked. 26/06/06 The home must be keep bedrooms free of offensive odours. Tiling missing and loose in the kitchen must be replaced and repaired. Previous timescale of 07/07/06 Staff must always have protective clothing such as aprons and gloves available to DS0000065186.V318034.R01.S.doc Timescale for action 01/02/07 01/02/07 2. OP18 13(6) 14/01/07 4. OP18 12(4)(5) 01/02/07 5. 6. OP19 OP19 16(2)(k) 16(2)(g) 01/02/07 01/02/07 7. OP26 13(3) 14/01/07 Withy Grove Care Home Version 5.2 Page 29 8. 9. 10. OP26 OP26 OP27 16(2)(e) 23(2)(d) 18(1)(a) 11 OP29 Schedule 2 12. OP33 12(5) use Sluice rooms must be kept cleaner. Ceilings and walls in the kitchen must be kept clean. 26/06/06 Sufficient numbers of staff must be employed for the health, welfare and safety of residents. Previous timescale 07/07/06 not met. Applications for employment must include a full employment history, together with a satisfactory written explanation of any gaps in employment. The registered provider and manager must in relation to the conduct of the home create an environment that encourages and assists staff to maintain good personal and professional relationships with residents/representatives. 14/01/07 14/01/07 28/02/07 14/01/07 14/01/07 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. 2. 3 4. 5. 6. Refer to Standard OP2 OP7 OP9 OP10 OP16 OP23 Good Practice Recommendations It is recommended residents be informed of any increase in their fees. It is recommended all residents benefit from care plans sufficiently detailed for staff to follow when caring for residents. It is recommended medication prescribed to be administered when necessary be detailed as to the circumstances it would be given. It is recommended a resident right to privacy be managed better. It is recommended the complaints procedure be promoted in the home. It is recommended the adjoining doors in bedrooms are DS0000065186.V318034.R01.S.doc Version 5.2 Page 30 Withy Grove Care Home 7 8 9. 10. 11 OP23 OP24 OP27 OP29 OP32 disguised to minimise confusion for residents in the dementia unit. It is recommended the labelling of drawers such as ‘vests’ should not be done unless it is to help people needing this level of support. It is recommended the emergency pull cords be connected in bedrooms identified in the inspection. It is recommended management take a positive attitude to the terms and conditions of staff employment. It is recommended a record be kept to verify a police clearance check has been carried out for all employees. It is recommended relatives/visitors and staffs views are responded to. Withy Grove Care Home DS0000065186.V318034.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Withy Grove Care Home DS0000065186.V318034.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. 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!