Inspection on 23/07/08 for Woodboro Residential Home

This inspection was carried out on 23rd July 2008.

CSCI found this care home to be providing an Adequate 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

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/10/2008.

CARE HOMES FOR OLDER PEOPLE Woodboro Residential Home 29-31 Skelmersdale Road Clacton On Sea Essex CO15 6BZ Lead Inspector Helen Laker Unannounced Inspection 23rd July 2008 10:00 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 DS0000071012.V366152.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. DS0000071012.V366152.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodboro Residential Home Address 29-31 Skelmersdale Road Clacton On Sea Essex CO15 6BZ 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) 01255 420090 01255 430991 Mr Emmanual Klotey-Tetteh Collison Mr Emmanual Klotey-Tetteh Collison Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22) of places DS0000071012.V366152.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category only: Care Home only - Code PC To service users of the following gender: Either Whose primary needs on admission to the following categories: Old age, not falling within any other category - Code OP Dementia - aged 65 years and over - Code DE (E) The maximum number of people that can be accommodated is 22 Date of last inspection Not Applicable Brief Description of the Service: Woodboro is an established care home, which has a registration for twenty-two older people aged 65 years and over, of whom all may require care by reason of dementia. The home has provision to incorporate care for two respite admissions and four interim placement (transitional) residents on short term care packages. Fees are £383.04 per week. Hairdressing, chiropody, dentistry newspapers and magazines are all charged at cost. Toiletries are charged at £3.50 per month and activities are charged at £20 per month with residents consent. The premises consist of a large family house, with an adjoining connecting bungalow, in a residential area of Clacton on Sea. Woodboro is within walking distance of the town centre and the rail station. Clacton on Sea has the usual amenities of shops, post offices, library and leisure facilities. The seafront and promenade are also close by. The accommodation comprises of twenty- two single rooms; nineteen with ensuite wash hand basin and toilet and three with wash hand basin only. Bedroom accommodation is on the ground and first floor. Access to the first floor is by staircases or passenger lift. Toilet and assisted bathing facilities are found on each floor. Catering and laundry services are in-house. Communal areas consist of a dining room, a main lounge room and a small quiet lounge/visitors room. All are located on the ground floor. There are gardens at the front of Woodboro. The rear of the property is paved for parking, with a patio area and the front gardens are laid with lawn and flowerbeds. DS0000071012.V366152.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. An unannounced site visit of Woodboro Care Home was carried out on 23rd July 2008 commencing at 10.00 am. The site visit lasted six and a half hours. This is the first inspection for the home under it’s new registration status effective from February 2008 which occurred due to the company changing to sole proprietorship and the addition of the DE (E) category for all residents. The inspection focused upon all of the key standards. A full tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment (AQAA) completed by the management of the home and submitted to the CSCI. The AQAA provides an opportunity for the service to tell us what they do well and areas they are looking to improve and/or develop. It is anticipated that some improvement be noted as this contributes to the inspection process and indicates the home’s understanding of current requirements, legislation changes and own audited compliance. This document will be referred to as the AQAA throughout the report. Three residents, four staff (care and catering) and the proprietor Mr Collison were spoken with during the inspection. The CSCI sent feedback/comment surveys to the home for both residents and relatives for completion prior to the inspection. Two have been received from staff, one from relatives, six from service users and two from care managers and the comments taken into account in the body of this report. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as staff rotas, care plans and staff files. Observations of how members of staff interact and communicate with people living there have also been taken into account. During the site visit four people who live at Woodboro were spoken with. All were generally pleased with the service and happy about way they are supported and assisted by the staff. They considered staff to be kind and helpful. On the day the inspector visited the home, the atmosphere in the home was initially strained due to a lack of staff on duty, however as the inspection progressed staff relaxed and were welcoming and we were given assistance from all staff on duty and the proprietor. DS0000071012.V366152.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Both the Statement of Purpose and the Service Users’ Guide have been reviewed and revised in February 2008. New furniture has been purchased and improvements have been made to fixtures and fittings repairs have been undertaken, making the surroundings pleasant for people living there. There have been improvements in medication practices and the way people are supported to make choices around activities. Service users were seen to have both variety and choice in the food they wished to eat. Clear management arrangements within Woodboro have been formalised. The roles and responsibilities of the registered manager/proprietor are clearly understood by Mr Collison (Proprietor) and the roles and responsibilities of the deputy manager as delegated by the registered manager are also clear. DS0000071012.V366152.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000071012.V366152.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000071012.V366152.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, and 5 Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into Woodboro, and their representatives will be provided with the information they need to make a decision if the home is suitable for them. They will have their needs assessed and will be provided with a contract, which clearly tells them about the service they will receive. Intermediate care is not offered at Woodboro. EVIDENCE: Both the Statement of Purpose and the Service Users’ Guide have been reviewed and revised in February 2008. At the site visit, Mr Collison, the registered manager confirmed this saying that he had been working on including the services available to support the DE (E) category and also equality and diversity within these two documents. DS0000071012.V366152.R01.S.doc Version 5.2 Page 10 Mr Collison said that all of the people living at Woodboro hold a copy of the Statement of Purpose and the Service Users’ Guide. These were seen on residents’ care files and copies are available in the waiting room also. Copies of these documents were given to us at the site visit and each was considered in detail following the site visit. These documents currently meet the standard required. Prospective residents have full and accurate information to help them decide whether or not the home can meet their needs and what services they can expect to receive. This was confirmed in service user surveys “My family were told and given a brochure” and “I came to look around also for some respite”. As part of the case tracking exercise the admission paperwork for four people who live in the care home was sampled and inspected. Two residents who had been admitted had had an initial assessment completed. Evidence of this was seen on their files. The third and fourth sampled were for residents who were admitted for respite and interim placements. At the site visit, evidence was found of completion of the admission process in full as detailed in the National Minimum Standards 2 – 4, namely the service user is provided with a statement of terms and conditions and the home ensures that a full needs assessment is completed with a care plan identifying how their needs are to be met. However a COMM 5 (Social Services Assessment) was seen for all files reviewed. The manager stated in a CSCI ‘ Have your say’ survey “We are not always given correct information in the COMM 5 documents” A discussion took place with the manager that whether for a short term placement or long term the pre admission process must be the same and the home should undertake their own assessment to ensure what care is required and what action is needed and by whom. Although this planning and record keeping was evident in part it was agreed with the manager and proprietor that it should be more organised to ensure that the resident’s individual needs are fully met and attention paid to the dating and signing of documentation. New paperwork for short term and long-term residents was shown to us at the inspection and it is to be implemented for all residents to ensure consistency. Woodboro does not offer intermediate care. DS0000071012.V366152.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals can be confident that their personal and healthcare needs will be met in Woodboro although to ensure service users healthcare needs and well being are monitored effectively, accurate recording and better organisation of documentation is required. People can be confident that they will be treated with respect and dignity. Medication management and arrangements ensure overall that the people living at Woodboro are safeguarded and protected. EVIDENCE: Care planning documentation was sampled and inspected for four people who live at Woodboro. Changes have been implemented into the plan of care devised for each person and evidence was seen of reviews. There was evidence of guidance for staff in ensuring personal care needs are met in the care plan. DS0000071012.V366152.R01.S.doc Version 5.2 Page 12 Daily record sheets were seen which detailed the food eaten by residents and health care issues detailed in the Manager’s Report sheet and the Medical Record sheet. Photographs of the people living at Woodboro are being collated and were found on some of the care planning documents seen. Overall the care planning documentation for two of the people who live at Woodboro was in good order as it gave clear guidance for staff as to how they should meet people’s care and support needs. However, the paperwork for the third and fourth person’s who had entered the home for respite care and an interim placements was not developed into a detailed plan of care but was in the form of an extended needs assessment. New paperwork for short term and long-term residents was shown to us at the inspection and is to be implemented for all residents to ensure consistency. Whilst it is recognised that this is still in process it is necessary for all residents to have full individually developed care plans to ensure what care is required and what action is needed and by whom. Reviews were seen and the AQAA states under how they have improved “Have trained eligible staff in record keeping and care planning”. Staff spoken with agreed that the new paperwork system should ensure consistency with the home’s care planning processes and that they had undertaken training in this area. The AQAA also acknowledges that the home expects “To update care practices to reflect new trends and ideas to further enhance individualised care”. The implementation of new care plans which are more person centred and ordered will create a more organised approach. Medical record sheets were seen on the care planning files sampled and these gave evidence of visits by healthcare professionals including doctors, consultants and district nurses. At this site visit, Mr Collison the registered manager said that an additional medication trolley had been purchased to facilitate safe secure storage for all medicines as they are being administered. The current practices in the home have been reviewed and revised, with medication either administered from the present medication trolley or from a secure storage box. Medication administration records (MAR) charts for four people who live at Woodboro were sampled and inspected at the site visit. Medication record keeping and administration was seen to be adequately completed. Within these records there was evidence of medication being brought into the home and being entered onto the medication administration records (MAR) charts. Records detailed medicines taken and refused and medication reviews were noted. Temperature records are kept for the medicines fridge and the room temperature and temazepam medication is kept in the controlled drug cupboard. The home is addressing the need to consider the provision of a photograph of the resident on medication records. DS0000071012.V366152.R01.S.doc Version 5.2 Page 13 During the site visit, the inspector observed occasions when good care practice was demonstrated with regard to knocking on doors and the serving of meals, and highlighted an issue surrounding the observation of a lack of interaction with service users even though the home was short staffed on the day of inspection. Surveys received from relatives were complimentary about dignity and choice, one said “I love it here I am well looked after”. Care planning records had evidence of thought being given to ensuring that the people living at the home are known by their preferred name and individual clothing is labelled either by staff or family. DS0000071012.V366152.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodboro provides people who live there with variety and choice. People living in the home benefit from maintaining good contact with family and friends and they are provided with a varied diet that they enjoy. EVIDENCE: We were told activities offered within the home have increased. Some evidence of attendance at activities was seen in care planning records, but it was not always possible to see if the people living at Woodboro had an opportunity to choose what they wished to do. More detailed one to one recording of social interactions would evidence this. The proprietor informed us that although there is a monthly charge for activities this usually cover external entertainers such as live theatre performances and an organist fortnightly who come to the home to entertain the residents. These are supplementary to the internal activities such as bingo, ludo, aerobic exercises offered within the home. However if service users do not wish to participate they are not charged for these events. DS0000071012.V366152.R01.S.doc Version 5.2 Page 15 During this inspection we were informed was told that the activities coordinator had recently left but there was an intention to appoint a carer with a responsibility for organising activity sessions as a dual role to her care duties. A record was kept of recent activities held in the home, including armchair exercises, craft activities, films and music and singing sessions. The staff are enthusiastic and keen to promote this aspect of care. They spoke of the ways in which they could circulate the information about activities in the home and ensure that it matches the expectations of the people who live in the care home. Consideration needs to be given to offering a mix of one to one and group activities and with a view to providing specific activities for those people with dementia. One person living at Woodboro had a photographic life storybook and this was recognised as being beneficial to that individual. All residents have an activity life storybook and some were seen evidencing lifestyle events such as family reminiscence and the war. The AQAA confirms, “Albums of compilation of activities carried out so far, exhibits of products are displayed on premises”. A few visitors were seen to enter the home throughout the day and they were able to meet with their relative in the main lounge, in their room or in the small quiet lounge. Relative/visitors comment cards were left with the home and one had been returned to the Commission for Social Care Inspection (CSCI). This stated, “staff made them welcome when they visited the home”. Those spoken to on the day of the inspection had no complaints and positively spoke about the home. Comments included “My relative is looked after well and the staff are good here” Mr Collison said that the home does not hold any money for any of the people living at Woodboro. This is normally managed by the person’s relative, solicitor or by the resident themselves. Within care plans records details were seen of personal possessions and an inventory is kept of items brought into the home. During this site visit, the inspector observed lunch being served. It was served on the plate with the majority of the residents having their meal in the dining room. Condiments, fruit squash and wine was available. A four-week rotation menu is in place, with at least two choices offered at lunchtime and teatime. One service user was noted to have chosen chicken instead of quiche and beans instead pf peas the catering staff showed a good knowledge of service users preferences and individual dietary needs. Food supplies are ordered and purchased throughout the week, with a variety of local suppliers and supermarkets used. There was a variety of food in store, including fresh, frozen, tinned and dried goods. Nutrition records evidenced choices made and the food eaten. DS0000071012.V366152.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. Service users can access the complaints procedure and generally be confident their concerns will be taken seriously, listened to and followed up. They can be assured they will be protected from abuse as staff have planned and ongoing appropriate training, and procedures and plans are in place to safeguard people living and working in the home. EVIDENCE: Woodboro’s complaints procedure and policy have been reviewed and revised in March 2007 to reflect the Commission for Social Care Inspection (CSCI) as the regulatory body. Copies were to be found in the home’s office and on display in the home. The Commission had received notification of a complaint raised by a relative. This complaint covered a number of concerns, some of which related to the care their relative received in Woodboro. Mr Collison was aware of this complaint and outlined the action taken by the home and it was noted that the action taken was in line with the home’s complaints procedure. The home’s AQAA highlighted “We have addressed (4)verbal complaints to the satisfaction of the complainants without it being taken any further. There are no written complaints regarding the standards of care”. DS0000071012.V366152.R01.S.doc Version 5.2 Page 17 Upon review of the home’s recording of the same it was noted that there were details of only one complaint being received and documented. The AQAA dataset confirms three complaints as being dealt with by the home. The formalising of recording of complaints was discussed with the proprietor on the day of inspection and documenting minor concerns as well as major complaints and recording the outcome would demonstrate that people’s concerns are taken seriously and acted upon. One of the comment cards completed by a relative and returned to the Commission for Social Care Inspection (CSCI), said that they had not raised a complaint, although they said they were aware of the home’s complaints procedure should they need to complain. Three others indicated that relatives were aware of how to make a complaint should the need arise. Service user comment cards offered positive comments saying “I love it here the management and staff are very kind.” whilst another said “there is no place like home but this is very close.” Policies and guidance with regard to adult protection were found in the care home local authority guidance and a training package also available. Within the home’s guidance there was information on the different types of abuse and Essex County Council referral forms were readily available. At the time of this inspection there were no safeguarding issues raised or pending. Protection of Vulnerable Adults (POVA) training had been planned for February 2008 but had not been undertaken and we were told this was to be rescheduled for all staff. DS0000071012.V366152.R01.S.doc Version 5.2 Page 18 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, 22 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, people living in Woodboro benefit from a homely environment that is clean and pleasant and improvements are made to ensure people remain safe. People may be confident that their bedrooms are comfortable and they are surrounded by their own possessions. EVIDENCE: A tour of the premises was undertaken at this site visit. There is an evident programme of routine maintenance and renewal of fabric and decoration at Woodboro, for decoration had taken place in most bedrooms. A loop system had been installed in the main lounge which residents spoken with said had helped tremendously. A new large screen TV has been purchased and new wall lights installed in the dining and large lounge area. The home’s accommodation is pleasant, homely and bright. DS0000071012.V366152.R01.S.doc Version 5.2 Page 19 All bedroom accommodation is single with all but three of the rooms having en-suite facilities. People who live at Woodboro had personalised their rooms, small items of furniture, pictures, ornaments and photographs. One person who lives at Woodboro said that they liked their room and they said they had been able to bring some photographs and pictures into the home. Some bedroom doors had the name of the person whose room it was, but many did not. This was discussed with Mr Collison. Consideration should be given to aiding all residents, particularly those with dementia to locate their room, through colour coding, pictures, and objects of pictorial reference or photographs on their bedroom door depending on the residents’ personal choice. The importance of colour, smell and touch should be considered when caring for people with dementia. Feedback from service users and relatives spoken with did not highlight any issues with the environment. Only one survey mentioned “The cleaning at weekends seems less obvious than at other times.” A side gate and back door were open on the day of inspection presenting a security risk, and also did not protect service users who may wander due to dementia onto a busy road area. We would have been able to just enter the home via this access without staff being aware. This was discussed on the day of inspection with the proprietor and deputy manager. All bedroom doors can be locked and there was evidence of risk assessments in place on the sampled care plans, which detailed why the particular person did not wish to hold a key and lock their room. In the Annual Quality Assurance Assessment (AQAA), Mr Collison, the registered manager and proprietor, had stated that the home wished to “ To provide “secure garden chairs” in the summer for outdoor recreations”. The rear of the property is a patio type area and four chairs and a table were in place. Woodboro has had an assessment of the premises and facilities by an occupational therapist. These assessments had been completed in March 2007 prior to new registration and copies of these reports were seen. The proprietor was reminded to ensure that these are kept up to date but the ones in place remain relevant to the homes present facility. Woodboro has it’s own laundry facility located at the rear of the ground floor. Within the laundry there is one washer and one dryer (industrial) and one domestic condenser/dryer. New larger capacity appliances have been purchased since the last inspection. Hand washing facilities and airing and drying facilities are in the laundry, with ironing completed by care staff overnight. Clean clothing is then placed in baskets ready to be returned to the people. DS0000071012.V366152.R01.S.doc Version 5.2 Page 20 To aid identification, Mr Collison said that new residents and their relatives are encouraged to label clothing with their name or care staff will label when a new resident is admitted. DS0000071012.V366152.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Woodboro overall benefit from a competent staff team but this is not always in sufficient numbers to ensure the people are safe and their individual needs are addressed. The home’s recruitment procedure does not always provide the safeguards to ensure that appropriate staff are employed and training needs addressed, to meet the needs of the residents. EVIDENCE: On the day of the inspection site visit there were nineteen people living at the home. Two care staff plus the manager were on duty. We were told that two staff were off sick on that day leaving the home short staffed and although agency were used to ensure there were sufficient staff on duty this had not been arranged to cover the shift that day. The proprietor who is also the manager arrived later and we were told he is usually on duty from 09.00am to 16.00pm weekdays with the exception of Thursday. Additionally the deputy manager is on duty 8.00am – 4.00pm each weekday. An on call system is available out of hours which consists of one member of care staff being available and the proprietor / manager can be contacted also. DS0000071012.V366152.R01.S.doc Version 5.2 Page 22 A monthly staff rota was in place and this detailed three care staff on duty throughout the day and three awake night staff. We were told that staffing levels are determined on the basics of the assessed needs of the people who live at the home. In the AQAA, Mr Collison acknowledged that there is a need to review staffing levels more frequently, and that the ratio of staff on nights has increased, particularly as the home has both short term interim placement beds (3) and respite beds (2) and is caring for people with dementia. The AQAA also highlighted that shifts were adequately covered but upon review the numbers of staff on duty were only sufficient in part and not sufficient on the day of inspection. It is of concern that one relative survey stated “The staff just manage when they are short and it always takes so much longer for people to be taken to the toilet”. A discussion took place with the proprietor and deputy manager and the importance of the home’s duty of care to ensure sufficient staff are on duty was made clear, despite possible cost implications being involved if agency staff are used. On the basis of this discussion the home is to review their current rotas and agreed to submit redeveloped rotas to the CSCI for review. This will be monitored at future inspections. Staff recruitment files for two care staff were sampled and inspected. The staff recruitment practice and record keeping highlighted some shortfalls. Evidence of one reference missing was found on one file, an incomplete application form and employment history and the statement of terms and conditions and job description offered to the care worker was not on the staff file. The other file reviewed showed similar shortfalls but did evidence the home was using the common induction standards. The home’s AQAA just states “Good recruitment selection process” More detail regarding this would have clarified the homes processes and better organisation is recommended. There was evidence that CRBs had been undertaken and were satisfactory. Mr Collison was reminded of the need to ensure that all staff are trained and competent to do their job. Evidence of staff induction was limited on the staff files reviewed and evidence of skills from their induction should be evidenced within their recruitment paperwork. Staff training records were not looked at in full at this inspection because evidence was not available in the form of certification, so it was not possible to see if training such as Moving & Handling, First Aid and Fire Training are undertaken by care staff on an annual refresher basis or at the intervals as recommended by the organisation that accredits the training. From the sample of records that were available it would appear that this is not always the case and further work is required on the development of an individual training and development assessment and profile. Within care staff files sampled there was evidence of some basic training courses such as Health & Safety, First Aid training, Client Handling Awareness and Care and Management of Dementia training. DS0000071012.V366152.R01.S.doc Version 5.2 Page 23 Staff attendance should be entered onto a training matrix, which would make it easier to highlight when updates are due. It was noted that the following courses had been booked and paid for staff to attend. Dementia Training – 19th August 2008 Moving and Handling – 1st August 2008 Medication Training - 5th August 2008 The AQAA also states that “6 staff enrolled for NVQ level 2, 1 staff enrolled on level 3, 1 staff enrolled for level 4” DS0000071012.V366152.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, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team of Woodboro generally ensure the home is run in the best interests of the residents. Some improvements with regard to health and safety need to be made so residents can be confident they are protected by the home’s practice and procedures. There is no formalised structured programme of supervision or quality audit in place to safeguard residents, whilst overall, safe working practices are promoted through ongoing training. EVIDENCE: Consideration has been given to the management arrangements in the home. Mr Collison said that he is looking to start a care management training course and is advised to investigate the value of his current professional qualifications DS0000071012.V366152.R01.S.doc Version 5.2 Page 25 in relation to achieving the registered managers award in care and management and the deputy manager has enrolled on a NVQ level 4. The AQAA states, “The structure consists of a Manager, Deputy Manager and a Supervisor which ensures effective line of responsibility and accountability. There is a key worker group headed by a senior carer who effectively is the named key worker for the group and for the residents listed under that group. The key worker is responsible in co-ordinating the care and overall function of the key worker role. There is good staff management consultation in the decision making process.” The proprietor Mr Collison states that Woodboro has a quality assurance and quality monitoring system in place. The AQAA does not mention anything with regard to this. No evidence of a formal monitoring system in the house was evident on the day of inspection. The management team need to build on the work they are doing around quality assurance and develop an action plan for the home that takes into account feedback from staff, relatives and people living in the home and to demonstrate how they take action. Mr Collison said that the home does not hold any money for any of the people living at Woodboro. This is normally managed by the person’s relative, solicitor or by the resident. Staff records were sampled for evidence of staff supervisions. Whilst there was some evidence of supervisions these had not been consistent and a planned programme of formal supervisions was not in evidence to ensure that supervisions take place at least six times a year. As highlighted previously in this report there was evidence of some basic training courses such as Moving and Handling. Future planned training includes Dementia and medication awareness. Servicing records for some appliances were sampled and inspected at this inspection. All were satisfactory and had been conducted in the last six to twelve months so were up to date. The one exception was the records relating to the fire alarm testing and fire instruction and drills. These had not been updated and completed in the recent months. Record keeping with regard to accidents, injuries, and incidents of illness or communicable diseases are recorded and reported. Accident records were sampled and were found to be accurate and in good order. Regulation 37 notifications are sent to the Commission and overall these give full details. DS0000071012.V366152.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 DS0000071012.V366152.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1)(2) (a)(b)(c) (d) Requirement People who use the service must be assured that they have a detailed care plan to ensure that all aspects of their health, personal and social care needs of are met. The needs of people who use the service who have dementia must be considered and accommodated within the care service e.g. identifying pictures, photographs or name labels on their bedroom doors and consideration of colour, smell and touch in furnishings and facilities offered. Staff numbers and rotas must reflect the staffing requirements to meet the dependency of the current service users. The home’s recruitment procedures must be robust and all staff must have appropriate checks in place before they start work, so that residents are protected. People who use the service must be assured they are safeguarded and protected by the DS0000071012.V366152.R01.S.doc Timescale for action 17/10/08 2 OP22 23(2)(h) 17/10/08 3 OP27 18 17/10/08 4 OP29 2 & 19 17/10/08 5 OP30 18(1)(a) (c) 17/10/08 Version 5.2 Page 28 6 OP36 18(1)(2) 19(1)(a) (c) 23(4) 7 OP38 development of a training and development assessment for all staff in both induction and basic training needs. People who use the service must be assured they are safeguarded by the introduction of regular, formal supervision sessions. People who use the service must be assured that they are safeguarded by the provision of basic training courses and fire alarm testing; fire instructions and drills are regularly undertaken. 17/10/08 17/10/08 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 OP2 Good Practice Recommendations People who use the service and are admitted in an emergency should be assured that they have a full assessment undertaken and they know that the home will meet their needs. The registered manager should obtain a qualification of NVQ level 4 in management and care (or the equivalent). This would ensure people living in the home benefit from a robust management structure in which the manager has obtained the qualifications needed to meet the National Minimum Standard. The home should ensure that quality audit systems are developed and ensure that systems within the home protect and safeguard service users. 2 OP31 3 OP33 DS0000071012.V366152.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000071012.V366152.R01.S.doc Version 5.2 Page 30 - 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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