Inspection on 03/09/07 for Woodbridge Lodge Residential Home

This inspection was carried out on 3rd September 2007.

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

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodbridge Lodge Residential Home 5 Burkitt Road Woodbridge Suffolk IP12 4JJ Lead Inspector Julie Small Key Unannounced Inspection 3rd September 2007 10:35 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 Woodbridge Lodge Residential Home DS0000069573.V350097.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. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodbridge Lodge Residential Home Address 5 Burkitt Road Woodbridge Suffolk IP12 4JJ 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) 01394 380289 01394 383638 Woodbridge Lodge Limited Mrs Janet Ann MacKinnon Care Home 32 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (32) of places Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/S Brief Description of the Service: Woodbridge Lodge is a large detached house, approximately half a mile away from the centre of Woodbridge. The home provides a very good standard of accommodation and facilities. There is a visitor car park at the front of the home, and the large garden at the back has been improved to include patio sitting areas, lawns, a pond, flowerbeds, trees, and shrubs. Ramps have been installed to enable service users to access the garden safely. The pond has been fenced off, for safety purposes. At ground floor level, there are two lounges, a large conservatory, a dining room, kitchen, staff areas, and nine service users bedrooms, each with en suite facility, plus communal bathroom and toilets. The first floor has a further nineteen service users bedrooms, nine of which have en suite facilities, plus communal bathroom and toilet facilities, a laundry, and separate sluice area. The second (top) floor provides a further four bedrooms, two with en suites, and a communal bathroom / toilet. A shaft lift connects all three floors of the home, in addition to two stair lifts, and three staircases, which continue to be used by service users who are more mobile and able. All bedrooms are occupied on a single basis, and the three communal bathrooms have a range of adaptations suited to the needs of older persons. All areas of the home continued to be well maintained and looked after. Bedrooms were individualised and homely in appearance and style. The lounges, conservatory, and dining room, were also pleasant environments, nicely decorated and furnished, with views out to the grounds. The home was changed from the registered provider being an individual person to Woodbridge Home Ltd in August 2007. At the time of the inspection, the manager reported that the weekly fees range from £460 to £600, depending on the size and location of the bedroom. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Monday 3rd September 2007 from 10.45 to 17.05. The inspection was a key inspection which focused on the core standards relating to older people and was undertaken by regulatory inspector Julie Small. The report has been written using accumulated evidence gained prior to and during the inspection. The home’s registered manager was on leave during the inspection and the home’s manager Kimberley Kenyon undertook managerial duties during this time. Miss Kenyon advised that she would be making an application for registered manager to CSCI (Commission for Social Care Inspection) in the near future. The manager was present during the inspection and provided requested information in a prompt and open manner. The manager said that service users were referred to as residents, this term will be used throughout the report. During the inspection a tour of the building and observation of work practice was undertaken. Seven residents were spoken with and one staff member was spoken with. Records viewed included three resident, three staff recruitment, training and health and safety records. Further records viewed are detailed in the main body of this report. Prior to the inspection an annual quality assurance assessment (AQAA) questionnaire and staff, visitors and residents surveys were sent to the home. The AQAA and eight service user, four staff and eight relative/visitor surveys were returned to CSCI. What the service does well: The home had a well maintained, clean, homely and attractive environment. Communal areas and resident’s accommodation was attractively furnished and comfortable. The home’s infection control procedures were good and there was hand wash liquid and disposable gloves provided throughout the home. There were no unpleasant smells detected during the inspection. Interaction between staff and residents was observed to be respectful and professional. The menus provided a nutritious and balanced diet and there was a range of options available. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 7 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 Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 8 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, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect that they are provided with the information they need to make a decision about moving into the home and that their needs are assessed prior to moving into the home. The home does not provide an intermediate care service. EVIDENCE: The home’s Statement of Purpose was viewed during the application for the first increase in numbers of dementia residents. The document was updated to meet the requirements during the application. The Statement of Purpose clearly identified information about the home, facilities and care provided, staffing and information about fire safety and the complaints procedure. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 9 A document, which was in picture and text format, which was in the process of being developed was viewed and the manager explained that it was a summary of the Statement of Purpose which was more accessible to residents living at the home. The relative/visitor survey asked if they received enough information about the home to help them to make decisions. Four answered always, three answered yes and one did not answer. The resident survey asked if they received enough information about the home before they moved in, so they could decide if it was the right place for them. Six answered yes and two answered no. Two commented that their children had received information and passed it on to them. Seven resident surveys said that they had received a contract and one said that they had not. Three resident’s records were viewed and all three held needs assessments completed prior to them moving into the home. The home’s pre-admission needs assessments included details of the name, address, reasons for admission, medical and health needs and wellbeing, abilities and interests. The home’s admission procedure was viewed and detailed that prospective resident’s were provided with a needs assessment undertaken in their home, the criteria for residents, the provision of visits to the home and a four week trial period before they decided if they wished to move in on a permanent basis. The procedure explained that prospective residents were provided with information about how to make complaints and a brochure about the home. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 10 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, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their needs are set out in an individual plan of care, that their health care needs are met and that they are protected by the home’s medication procedures. Residents can expect that at the time of death, staff will treat them and their family with care, sensitivity and respect. EVIDENCE: Three resident’s care plans were viewed and they provided detail regarding their needs and actions staff should take to meet their needs. The care plan included details regarding their mobility, personal hygiene, their likes and dislikes and preferences. One resident’s care plan stated that their original language was not English, however, they spoke English well. The care plan identified that they lived in Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 11 another country prior to moving to the United Kingdom, however, there was no clear reference to their origins and any specific cultural needs they had. The care plans were completed on a booklet called ‘Assessment for Good Care Planning’, which included the care plans, a personal profile and assessments on needs, medical, mental health, moving and handling, personal risks, physical health, pressure sore and falls. There were monthly evaluations and reviews undertaken by the key worker. The AQAA stated that the home involved families in six monthly reviews and that the feedback was excellent. There was clear reference to risks that they faced in their daily living and methods of minimising the risks were clearly identified. The resident survey asked if they received the care and support they needed and eight answered always. The relative/visitor survey asked if the care home met the needs of their relative or friend. Five answered always and three answered usually. The staff survey asked if they were given up to date information about the needs of the people they supported. Two answered always and two answered usually. Comments included ‘All doctor’s visits are recorded in care plans any change in medication is also noted’ and ‘We are given up to date information on a daily basis each time we do a shift change. We are also given the correct information if there are any changes to their daily care routine. The information on each resident is always at hand’. The daily records were viewed and identified the wellbeing and support provided to residents and identified how residents had chosen what they wanted to do on a daily basis. The records were stored in a ring binder type file and there were remaining records regarding service users who had died. It is recommended that completed records be filed in the resident’s personal files on a regular basis to ensure that personal information is not stored in the file when completed. The home had a ‘report book’, which included significant daily reports on each resident, which included issues such as visits from medical professionals. The book also included information such as when a resident had been incontinent. The manager was spoken with regarding the confidentiality of personal information and alternative methods of recording. The resident’s records viewed provided clear information of health care visits and treatments, including dental, medical, chiropody and optical. Actions were clearly recorded following the weight loss of a resident, which included contact with the family and health professionals. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 12 During the inspection there was a visit from a medical professional, to which several residents spoke with in a private area of the home and staff were observed to give and receive feedback from them. The resident survey asked if they received the medical support they needed and eight answered always. The home’s medication storage and lunchtime medication administration was observed. Medication was in a secured trolley, which was stored in a lockable room when not in use. The medication records were viewed and clearly identified medication prescribed for each resident. There were no gaps identified in the records viewed. A staff member clearly explained the procedure for ordering and disposing of medication. During a tour of the building, staff were observed knocking on bedroom doors before entering and they asked for the resident’s permission for the inspector to look at their bedroom. They introduced the inspector to residents and explained why they were in the building. Interaction between residents and staff was observed to be friendly, respectful and professional. Residents spoken with confirmed that the staff treated them with respect and respected their privacy. Staff spoken with said that resident’s clothing was labelled to ensure that they were provided with their own clothing when it had been laundered. The resident survey asked if the staff listened and acted on what they said and eight answered yes. Several letters and thank you cards from relatives were viewed, which thanked the staff at the home for the care and support they had provided to individual residents. There was reference to how both the residents and family members were supported with kindness and sensitivity during illness and death. The home’s procedures were viewed and included care of a dying resident, caring for residents who are terminally ill and procedure in the event of death. Daily records viewed evidenced the support provided to the resident and their family at the time of death and identified when the family were with the resident at the time. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 13 Woodbridge Lodge Residential Home DS0000069573.V350097.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, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are provided with the opportunity to participate in their chosen interests, that they are supported to maintain contact with their relatives and friends, that they are supported to make choices in their lives and that they are provided with a balanced and appealing diet. EVIDENCE: The resident’s care plans viewed identified their interests, hobbies and any religious worship, which they participated in. During a tour of the building it was noted that there was a large range of entertainment available such as videos, books and games. During the afternoon of the inspection residents were observed playing bingo. The activities programme was viewed and included lunch out, buffet tea on the patio, cheese and fruit tasting, parties, bingo, quizzes, arts and crafts and music and movement. There were a range of visiting entertainers such as Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 15 ‘zoolab’, where animals were bought into the home for residents to look at and touch. The AQAA stated that activities were tailored to service user’s needs and abilities and that the home organised both summer and winter open days where resident’s families and friends were invited. Residents spoken with said that there was enough to keep them occupied at the home and that there was a visiting library for those who could not get out. One resident said that they went for a walk to the local shops on a daily basis and went out to visit friends. A resident was observed preparing to go for a walk around the garden, they said that they enjoyed the grounds and showed the inspector a range of potted plants on the patio outside their bedroom, which a family member had potted. A resident said that they had a bird table and enjoyed watching the birds from their room. The resident survey asked if there were activities arranged by the home which they could take part in. Six answered always, one answered usually and one did not answer, one commented ‘which I enjoy daily’. A newsletter was viewed, which was sent to residents and their families. The newsletter gave updates of various activities, including photographs, resident’s birthday parties, staff changes and qualification achievements and forthcoming activities and outings. There was a reminder that Holy Communion, visiting hairdressers, chiropody and manicures and pedicures were offered on a monthly basis. A staff survey stated that there was a Catholic service provided on a weekly basis. Residents reported that their family and friends could visit the home and were made welcome. There were hot and cold drinks facilities which residents and visitors could help themselves to. There were several visitors observed at the home throughout the inspection. The relative/visitor survey asked if the home helped their relative/friend to keep in touch with them. Six answered always and two answered N/A. The survey asked if they were kept up to date with important issues, seven answered always and one answered usually. Residents spoken with said that they could bring their personal possessions into the home if they wanted to. A resident said that they had bought their own easy chair into the home. They said that they chose what they wanted to do in their daily lives. Resident’s records and minutes from house meetings were viewed and evidenced that residents made choices about their daily living including what they wanted to eat and what activities they wished to participate in. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 16 The menu for the day was displayed on a chalk board on the wall in the dining area. The menu was viewed and there was a choice of meals, including supplementary menus such as omelettes, salads and jacket potatoes. Lunch was observed during the inspection and the meals looked and smelled appetising. There was a range of soft drink provided and a glass of wine for those who wanted it. Residents spoken with said that the food was of good quality and they were provided with enough to eat. Residents were provided with choices of hot and cold drinks throughout the day of the inspection. Resident’s specific dietary requirements were identified in their care plans. A staff survey commented that they were informed about resident’s dietary requirements, preferences and allergies. The resident survey asked if they liked the meals at the home. Six answered always and two answered usually, comments included ‘especially the lunches which are very good and well presented’, ‘lovely’ and ‘I enjoy my meals’. The AQAA stated that they were continually complimented on the quality of their home cooked food. Woodbridge Lodge Residential Home DS0000069573.V350097.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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their complaints are acted upon and that they are protected from abuse. EVIDENCE: The home had a complaints procedure, which included CSCI (Commission for Social Care Inspection) contact details, which was included in the home’s statement of purpose. There had been complaints made since the last inspection. A range of ‘thank you’ letters and cards were viewed. They had been sent to the home by resident’s family members, thanking the home for the support they had provided. The relative/visitor survey asked if they knew how to make a complaint. Six answered yes and two answered no. The survey asked if the home had acted appropriately if they had raised concerns. Five answered always, one answered usually and two answered N/A. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 18 Eight resident surveys said that they knew who to speak to if they were not happy and if they knew how to make a complaint. One survey provided the comment ‘I am happy here’. Three staff surveys said that they knew what to do if a resident or relative had concerns about the service. On arrival at the home the inspector was asked for identification and to sign the visitors book. Staff spoken with confirmed that they had received POVA (Protection of Vulnerable Adults) training and were aware of the procedure for reporting and recording any concerns or allegations of abuse. The home had clear POVA procedures. The AQAA stated that staff were aware of the home’s policies and procedures. The training records viewed evidenced that all staff were provided with POVA training. The AQAA stated that the home did not involve itself in the resident’s financial affairs. Woodbridge Lodge Residential Home DS0000069573.V350097.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, 21, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they live in a clean, safe, well maintained environment. EVIDENCE: The home was well maintained, homely and attractively furnished. It was noted that the home was very clean and domestic staff were observed undertaking their duties, which including cleaning the legs of a mobile table, which they said that they did on a daily basis. There had been efforts made to ensure that the home was homely which included paintings on the walls and flowers in the communal areas. Residents spoken with were complimentary about the environment. The AQAA stated that the home had an ongoing refurbishment programme. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 20 There was a large dining area, where residents were observed to be enjoying their lunch during the inspection. The tables were attractively laid and there were flowers on each table. There were two lounges, which residents could choose to use. There was a large conservatory, where several residents were sitting. The conservatory had comfortable seating and views of the garden. Bedrooms viewed were clean and well maintained. Each bedroom had the resident’s personal memorabilia in them and reflected their choice and personality. Residents spoken with said that they were happy with their bedrooms, two said that they enjoyed the view of the garden and they had large doors which opened onto the patio area. There was a large attractively landscaped garden with seating which residents could use. Communal bathrooms and toilets were sufficient in number and provided supported facilities for the use of residents. There was a choice of showers and baths. The majority of bedrooms provided and en suite facility comprising of a hand wash basin and toilet. All communal bathrooms and toilets included hand wash liquid, disposable towels and gloves. During a tour of the building it was noted that the home was well ventilated and lighting was sufficient to meet the needs of residents. Radiators had safety covers, which fitted with the décor of the home. Prior to using the bath, water temperatures were checked and the inspector was informed that all outlets had safety valves. The laundry was viewed and it was clean and tidy. There was hand washing facilities provided in the laundry. Washing machines provided adequate programmes to ensure that soiled laundry was laundered appropriately. There were no unpleasant odours in the home during the inspection. Fifteen resident surveys said that the home was always fresh and clean. The home had procedures regarding infection control and clinical waste. During the inspection staff were observed undertaking good infection control procedures, which included hand washing and wearing of protective clothing. In the entrance hall to the home, there was hand cleansing liquid with a notice inviting visitors to use it. The inspector was informed that there was hand cleansing liquid provided throughout the home. The resident survey asked if the home was fresh and clean and eight answered always. Comments included ‘the standard of cleaning is excellent’, ‘the home is beautiful’, ‘good facilities, particularly appreciate the garden’ and ‘I love my room’. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 21 There were complimentary comments about the environment in the relative/visitor surveys, which included ‘it is kept very clean’ and ‘ …the rooms are clean and tidy, the garden is a dream to sit out in the summer’. Woodbridge Lodge Residential Home DS0000069573.V350097.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 good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their needs are met by trained staff and competent staff and that they are protected by the home’s recruitment procedures. EVIDENCE: The staffing rota was viewed and showed that there were care staff on duty twenty four hours each day, with domestic and catering staff providing support. The AQAA stated that they had a high level of staff members on each shift and that there was always a senior staff member on duty. Staff spoken with said that there was sufficient staff on duty at all times and said that if there were instances of sickness, the shift would be covered straight away. The manager said that the home was fully staffed and that several staff had worked at the home for several years. Staff said that they were given opportunities to participate in training and development activities and listed training which they had attended, which included POVA, first aid, manual handling, fire safety, dementia and safe handling of medication. Training records viewed confirmed that the staff team were provided with the training explained by staff. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 23 The staff survey asked if they were given training which is a) relevant to their role, b) helps them to understand and meet the individual needs of residents and c) keeps them up to date with new ways of working. Four answered yes to all the questions and comments included ‘we have regular in house training on all aspects, as well as outside agencies i.e. fire service, first aid training’ and ‘the manager keeps us informed of any new rules or regulations that have been made and we have regular training sessions which keeps us up to date. We have recently done fire training, food and hygiene and handling and lifting’. The relative/visitor survey asked if staff had the right skills and experience to meet the different needs of people. Six answered always and two answered usually. The induction workbook was viewed, which identified that staff were provided with the information identified in the Skills for Care Common Induction Standards. The staff survey asked if their induction covered everything they needed to know about the job before they started. Four answered yes and one commented ‘we have in house training for two weeks before going to residents alone’. The AQAA stated that eighteen care staff worked at the home, ten had achieved an NVQ (National Vocational Qualification) level 2 or above and two were working toward their NVQ level 2 or above. The home had met the target in the National Minimum Standards related to older people that 50 of staff achieve a minimum of NVQ level 2 by 2005. Three staff recruitment records were viewed and included the required information, including two written references, evidence of CRB (Criminal Records Bureau) checks, application form, identification and a photograph. The staff survey asked if the employer carried out checks, such as their CRB and references before they started work and four answered yes. Woodbridge Lodge Residential Home DS0000069573.V350097.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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that the home is managed by a person who is fit to be in charge, that the home is run on their best interests, that their financial interests are safeguarded, that staff are appropriately supervised and that their health and safety is protected. They cannot be assured that the home routinely makes Regulation 37 notifications to CSCI. EVIDENCE: During the inspection the manager informed the inspector that the registered manager was reducing their duties and the manager was undertaking an increased role. They said that they were due to make a registered manager Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 25 application to CSCI. This was confirmed in the AQAA. They confirmed that they had achieved the NVQ level 4 registered manager award, which was a combination of care and management, their certificate was viewed. They were receptive to the inspection process. It was noted that there had been nine resident deaths in 2007, from the daily records which were viewed and the AQAA stated that there had been 8 deaths at the home and three at hospital since the last inspection. There had been no Regulation 37 notifications made to CSCI. The manager was unsure if they had been completed and confirmed that they would check with the registered manager. There were regular quality assurance satisfaction questionnaires for residents and visitors. There were records of responses to any concerns raised in the questionnaires by letter to the individuals, identifying the actions the home had taken to improve the service. The AQAA stated that further activities, which sought the views of the service from residents, included frequent resident meetings, a suggestion box and care plan reviews. Staff spoken with confirmed that they were provided with regular one to one supervision meetings, which were recorded. They said that they felt that they were supported in their work role. The staff survey asked if the manager met with them to discuss how they were working and four answered regularly. Staff records viewed evidenced that staff were provided with supervision and annual appraisal meetings. There were records of regular supervision and assessments, where staff were supported with specific issues and observed in their usual work practice. A staff member spoken with said that they were unaware that they were being observed in their work practice and that the manager discussed issues regarding their work practice following the observation. They said that the assessments were good and helped improve their practice. There were records, which identified staff strengths in specific tasks, and any further training they required. Accident records were viewed and they were appropriately recorded and reported. There was evidence viewed of regular fire safety checks and evacuation. Health and safety related records were viewed and there was documentary evidence which included electrical appliance testing, gas safety checks and water temperature checks. There were records that evidenced that the hoists and lift were regularly serviced. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 26 The home had a valid certificate of liability, which was displayed in the entrance hall to the home. Staff training records evidenced that staff were provided with health and safety related training such as manual handling, fire safety and food hygiene. There were detailed policies and procedures which identified how the health and safety of the home and resident’s was promoted and protected and included emergencies and crises, moving and handling and infection control. A door, which opened to the car park, had been fitted by a key pad lock, which could be opened in an emergency, since the last inspection. Environmental risk assessments were viewed and there was a detailed risk assessment for each room in the home. Residents maintained their own finances and the manager advised that any charges, such as for chiropody were invoiced to the resident or their family members. Woodbridge Lodge Residential Home DS0000069573.V350097.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 X X 3 3 4 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 2 X 3 X 3 3 X 3 Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP37 Regulation 37 Requirement Regulation 37 notifications must be routinely forwarded to CSCI Timescale for action 30/09/07 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. Refer to Standard OP7 OP7 Good Practice Recommendations It is recommended that consideration to an alternative method of recording in the ‘report book’ be used to ensure resident confidentiality. It is recommended that daily records be regularly transferred from the daily record file into resident’s personal records. Woodbridge Lodge Residential Home DS0000069573.V350097.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Woodbridge Lodge Residential Home DS0000069573.V350097.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. 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!