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Inspection on 19/11/07 for Woodcross Mental Nursing Home (Highfields)

Also see our care home review for Woodcross Mental Nursing Home (Highfields) for more information

This inspection was carried out on 19th November 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There is a stable group of staff, with many staff having worked at the home of a significant length of time. The staff team have a balance of skills, knowledge and experience to meet the individual needs of people who use the service, and have developed good relationships with individuals. The people who used the service spoke highly of the staff team. Comments regarding the staff team include; `the staff are great`, `the staff don`t take your independence away`, if things are bothering you, they`ll listen`. The management team in the home support staff to develop their skills and become experts in different areas. This means that staff teach their peers the skills and knowledge they need to be able to carry out their work, and this has helped to develop good team work. Individuals are able to maintain contact with family and friends and access the community. The staff are committed to retaining individuals independence and building on the existing skills of individuals. The home provides a wide variety of opportunities for people to participate in community activities. There is a weekly trip to a local place of interest chosen by the people who use the service. Individuals are able to access local community facilities independently following an assessment of risk. Staff support people to retain living skills and people can participate in daily household tasks, including domestic duties and cooking. People in the home are able to look after their finances and have a locked facility in their room to keep money and valuables safe. People who use the service are able to personalise their rooms to reflect individual interests. A number of rooms are shared and the home has provided facilities to ensure privacy.

What has improved since the last inspection?

The service provider has recruited a manager to the home, who has been in post for a significant length of time. The manager has reviewed the plans of care and practices in the home. The outcome of the review is a team approach to the care and support, and a staff team that feel valued and supported. The staff demonstrated they were confident to provide a good quality service. People who use the service clearly reported that they have confidence in the manager and the staff team. An Activity Co-ordinator has been recruited and the level of activities both within the home and the community has increased. People are able to go on weekly trips to places of interest, attend local clubs and maintain and develop living skills in the home.

What the care home could do better:

The service provider needs to ensure the home has a registered manager as required by the Care Standards Act 2000. The manager is in post and needs to submit an application to begin the Fit Person process following suitable clearance from the Criminal Records Bureau. Plans of care are detailed and focus upon the health needs of people who use the service. A review of the plans needs to be conducted to ensure they reflect all individual`s needs and support required, based on a person centred approach to care. A small number of plans were the same for each individual and assessments of risk were carried even when a risk had not been identified.People who use the service need to evidence their involvement and agreement to any restriction in place. The registered person needs to explore methods of including people or recording methods when people have chosen not to be involved.

CARE HOME ADULTS 18-65 Woodcross Mental Nursing Home (Highfields) Woodcross Mental Nursing Home 23 Reeves Street Bloxwich Walsall West Midlands WS3 2DG Lead Inspector Mandy Brassington Key Unannounced Inspection 19th November 2007 09:40 Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 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 Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.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 Adults 18-65. 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. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodcross Mental Nursing Home (Highfields) Address 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) Woodcross Mental Nursing Home 23 Reeves Street Bloxwich Walsall West Midlands WS3 2DG 01922 497394 01922 497395 woodcross@schealthcare.co.uk Southern Cross Healthcare Centres Limited vacant post Care Home 44 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (44), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (44) Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 42 Mentally Ill adults from the age of 18 years. 3 of whom may be on Section 7 of the Mental Health Act 1983 (Guardianship Order) 1 named resident on Section 42 of the Mental Health Act restriction. Date of last inspection 21st July 2006 Brief Description of the Service: Woodcross Nursing Home is registered to accommodate 44 adults with enduring mental health issues and associated conditions. A small number of people have a physical disability, although this is not their primary need. The home is a purpose built two-storey building. On the ground floor there are three lounge areas, one being a smoking room. There is a large dining area with a serving hatch to the kitchen. The home has toilets and bathrooms situated throughout the home. There are two sluice areas and professional laundry facilities. The home has single and shared bedrooms, none of which have en-suite facilities. There is an enclosed garden at the side of the home, with a patio ara and barbeque facilities. The home has a minibus for use by people who use the service. The home is located near the centre of Bloxwich with local bus services, shops and other amenities close by. The Service User Guide did not reflect information relating to the fees in the home as required. The reader may wish to approach the care provider for up to date details of the fees payable. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered the core standards. The inspection took place over 7.5 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. Prior to the inspection the manager had completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. One completed questionnaires was returned from a professional person. A tour of the home was undertaken and a meal was eaten with people who use the service. On the day of the inspection, the home was accommodating forty-two people. The inspection included an examination of records, indirect observation, discussion and observation of people who use the service, and staff on duty. Four Plans of care were examined along with four staff records. Observation of daily events took place. Inspection of the storage system and medication procedures were inspected. Five requirements and two recommendations were made as a result of this visit. What the service does well: There is a stable group of staff, with many staff having worked at the home of a significant length of time. The staff team have a balance of skills, knowledge and experience to meet the individual needs of people who use the service, and have developed good relationships with individuals. The people who used the service spoke highly of the staff team. Comments regarding the staff team include; ‘the staff are great’, ‘the staff don’t take your independence away’, if things are bothering you, they’ll listen’. The management team in the home support staff to develop their skills and become experts in different areas. This means that staff teach their peers the skills and knowledge they need to be able to carry out their work, and this has helped to develop good team work. Individuals are able to maintain contact with family and friends and access the community. The staff are committed to retaining individuals independence and building on the existing skills of individuals. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 6 The home provides a wide variety of opportunities for people to participate in community activities. There is a weekly trip to a local place of interest chosen by the people who use the service. Individuals are able to access local community facilities independently following an assessment of risk. Staff support people to retain living skills and people can participate in daily household tasks, including domestic duties and cooking. People in the home are able to look after their finances and have a locked facility in their room to keep money and valuables safe. People who use the service are able to personalise their rooms to reflect individual interests. A number of rooms are shared and the home has provided facilities to ensure privacy. What has improved since the last inspection? What they could do better: The service provider needs to ensure the home has a registered manager as required by the Care Standards Act 2000. The manager is in post and needs to submit an application to begin the Fit Person process following suitable clearance from the Criminal Records Bureau. Plans of care are detailed and focus upon the health needs of people who use the service. A review of the plans needs to be conducted to ensure they reflect all individual’s needs and support required, based on a person centred approach to care. A small number of plans were the same for each individual and assessments of risk were carried even when a risk had not been identified. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 7 People who use the service need to evidence their involvement and agreement to any restriction in place. The registered person needs to explore methods of including people or recording methods when people have chosen not to be involved. 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. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home only take place after a comprehensive assessment. People are able to spend time in the home prior to deciding whether to move in. EVIDENCE: The home has a Statement of Purpose available for all people in the home. Discussion with the manager confirmed that the Statement of Purpose needs to be reviewed, to reflect the service provided to people who use the service. As part of the visit a review of the Registration of the home was conducted, the conditions of registration are contained within the Statement of Purpose. Each person has a Service User Guide that sets out the objectives and philosophy of the home, and includes services provided by the home. The Service user Guide does not include details of fees payable as required. There was one new referral to the home during the week of the inspection and examination of records revealed that a full needs assessment was completed by senior staff in the home, along with a Care Management Assessment. The Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 10 manager reported that a senior member of staff would complete an assessment prior to admission and a further assessment would be conducted when the person was in the home. Examination of records identified that the person had a plan of care devised in the first week. Discussion took place regarding exploring options for evidencing people’s involvement in the formation of the plan. People living in the home confirmed that they were able to visit prior to deciding to move in. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each individual has a plan of care that includes information to support the person to keep well, but does not evidence people’s involvement in the development and review and agreement to the plan. The plan and risk assessments are not always person centred and cover the same areas for all individuals. People who use the service are involved in some decision making about the home, such as day to day living and social activities. EVIDENCE: Each person has a plan of care that includes personal information and contact details, identified health needs and any required medical intervention, mental health related concerns, any alcohol dependency, any restriction relating to smoking or drinking and support required with any personal care. The plans Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 12 are detailed and provide information relating to promoting mental health and well-being. The plans are written by nursing staff, who confirmed that where possible, people who use the service are involved in the formation and review of any plan; this was not evidenced. Assessments of risk are completed for many eventualities and reviewed each month, including moving and handling, pressure care, bed rails, nutrition and falls. These were discussed with the manager, as each individual had an assessment of risk completed whether this had been identified as an area of concern, which means that the plans were not tailored to individual needs. The plans of care were discussed in detail with the manager as they are not always person centred. There was evidence of a small number of generic plans of care for specific areas of need, for example, support with personal hygiene. From discussion with staff important information relating to daily care practices was not included; for example, staff are able to support one person when they become agitated, by watching a movie, or sitting talking with in their room. The plan focused on the medical needs of people rather than daily events and support required. It is required that the plans be reviewed to demonstrate how people who use the service or their representative are involved in the formation and review of their plan. Where there are restrictions in place, the limitations and decisions made by the person and recorded and agreed. People who use the service are aware they have a plan of care; three people stated they did not wish to see their plan. Staff reported that people are able to access personal plans and two people ask to see them on a regular basis. Trained staff write a daily report of activities, and support staff write a weekly diary of events. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use service are able to enjoy a varied lifestyle with different options to choose from. Routines are very flexible and people can make choices in all areas of their life. Personal relationships are encouraged and people are able to develop and maintain relationships. EVIDENCE: Around the home were photographs of the many events and trips that people who use the service are able to participate in. Discussion with individuals revealed that the home has a minibus and trips are organised each Friday to local places of interest. A small number of individuals also chose to go on holiday to Butlins. Trips had been organised included to a zoo, Ironbridge and Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 14 Telford, Cosford Air Museum and a local Farm. One person stated, ‘we get to go wherever we want, they’re very good. I never used to go out anywhere, but now I go whenever I can.’ The manager reported that a review of all activities had been conducted in line with the preferences of individuals. As a result, there was greater participation by people. Two people reported that they enjoy attending a local Club on a monthly basis, where activities and social events are arranged. One person said, ‘ we get to meet other people there, we’re going there over Christmas, we always get a present.’ People who use the service have access to a range of activities in the home. On the day of the inspection, some people were participating in arts and crafts and one person was completing some work on the computer. During lunch, individuals commented that a game of Bingo was planned during the afternoon, where prizes could be won. The home has an activities room with kitchen facilities. One person commented that they had made some cakes for ‘Children in Need’ for people to buy. Staff reported that people are encouraged to retain their living skills and can cook with staff support and prepare individual meals. The home is situated near local shops and facilities and staff reported that individuals are able to leave the home independently, and this was observed throughout the day. Staff reported that where people feel vulnerable or choose to have support, staff would facilitate this. Two people reported that there are two local churches, and confirmed that some people attend the services. Staff stated that the local facilities reflect the religious observance of people living in the home. Individuals are able to maintain close contact with friends and family and visitors can be seen in private. One individual reported he has a close personal relationship, and staff understand and respect people’s relationships. A small number of people stay for short periods of time at the family home. The menu is displayed in the main dining area, and people confirmed they were aware of the planned meals. On the day of the inspection, for lunch, individuals were able to choose from Jacket Potato with cheese and salad, or a mixed grill. Dessert consisted of chocolate sponge and custard. All people spoken with reported the meals were of a good quality, and a range of meals were provided. There was a relaxed atmosphere during the meal and individuals were observed freely talking and socialising with other people. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use service and are encouraged to be independent, have regular appointments and visit local health care services. The home has an efficient medication policy supported by procedures, practice and guidance for staff. EVIDENCE: Plans of care contain detailed information relating to individuals health care needs. A record is maintained of visits to health care professionals and a record of any outcome of appointments. Inspection of records demonstrated the health care needs, form part of the initial assessment carried out by trained staff in the home. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 16 All people are registered with a local General Practitioner. Discussion with people who use the service revealed that they are able to visit the doctor in private, or can choose to have support from staff. At all times, a registered nurse leads the team of staff in the home. The manager reported that the trained staff have the skills and knowledge to recognise and identify signs of ill being, including changes in peoples mental health, therefore early intervention can take place to reduce any significant ill health or deterioration. There have been a small number of deaths in the home since the last inspection and one person reported, ‘the staff are very good when something like that happens, they really help you. We can go to the funeral if we want.’ The home has two mobile hoists for people who also have a physical disability. Discussion with staff revealed that one support staff has completed training to become a Moving and Handling trainer, and delivers this training and support to all the team including safe use of equipment. The Monitored Dosage System (MDS) is used and one trained member of staff takes the lead for all aspects of medication. Medication is stored in a locked room within two mobile trolleys. The room also has additional storage facilities for Controlled drugs and medical supplies. The member of staff responsible for medication demonstrated there are excellent procedures for ordering, stock control, and administration. There were robust auditing systems in place and the staff demonstrated excellent knowledge of medication, systems and knowledge of drug useage. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and is supplied to everyone living at the home. The staff understand the procedures for Safeguarding Adults and have a good knowledge of procedures and how to respond to an alert. EVIDENCE: The home has a Company complaints procedure that is clearly written. The complaints procedure was displayed in home and discussion with people who used the service revealed that they had a clear picture of the role of the Commission for Social Care Inspection (CSCI). The CSCI office contact details had been changed to the regional office. The manager reported that there had been no recorded complaints from people who use the service. Discussion took place, regarding recording verbal concerns to demonstrate how the home responded to individual’s issues. There have been no complaints received by CSCI since the last inspection. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 18 Discussion with staff and inspection of staff records confirmed that staff had received training for recognising signs and types of abuse. Staff spoke confidently about how to respond to an alert and the process. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The home is well maintained and provides specialist aids and equipment to meet the needs of the people who use the service. Bedrooms are personalised to reflect individual’s interests and privacy curtains are provided in shared rooms. EVIDENCE: The home is a purpose built two-storey building. On the ground floor there are three lounge areas, one being a smoking room. There is a large dining area with a serving hatch to the kitchen. The home has toilets and bathrooms situated throughout the home. There are two sluice areas and professional laundry facilities. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 20 The home has single and shared bedrooms, none of which have en-suite facilities. The rooms were personalised to reflect the interests of the individuals. A number had a large amount of personal possessions and equipment. The manager reported that the home is reviewing the decoration with the people who use the service, and aims to redecorate bedrooms according to people’s preferences. Where people share a room there are privacy curtains in place. There is an enclosed garden at the side of the home, with a patio area and barbeque facilities. The home has a minibus for use by people who use the service. One corridor to bedrooms 30 – 32 had a strong odour. Staff reported that this smell is constant, though varies in its strength. The manager reported that the drains and pipes have been checked. One person, whose bedroom is in this area reported that ‘some days it makes you feel sick’. It is required that further investigation and work be carried out in this area to resolve this. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use service have confidence in the staff that care for them and staffing provided in the home reflects individuals needs. Staff participate in mandatory training, and some staff have undertaken additional training and take a lead role in support and training in specific areas. The service has a good recruitment procedure to ensure appropriate checks are carried to ensure people are suitable to work in the home. EVIDENCE: On the day of the inspection the manager was working in a supernumerary capacity from 8.00am to 5.00pm. The staff on duty consisted of: 1 Qualified Nurse (Mental Health) working 8.00am – 8.00pm 4 Support workers from 8.00am – 8.00pm 1 Activity Co-ordinator working from 8.00am – 4.00pm Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 22 2 Domestic staff working 8.00am – 1.00pm 1 Cook working 8.00am – 4.00pm 1 Kitchen assistant working 9.00am – 5.000pm During the night there are four staff on average, including trained nurses in charge of the shift. The manager confirmed that usual pattern of shift is five people working a day shift and four people working a night shift. Inspection of the roster revealed that the manager and activity co-ordinator’s hours worked in the home were not recorded, and the roster did not reflect the actual hours being worked for all staff. It is recommended that this be included to demonstrate the staffing provided in the home. A deputy manager has recently been recruited from within the home and is planned to start working later in the month to support the manager. A percentage of the Deputy’s hours will be supernumerary. People who used the service spoke positively about all members of the staff team and reported, ‘the staff are great’, ‘ the staff don’t take your independence away, and if you want to help there’s always something we can do. I like being able to do things’, and ‘if things are bothering you, they’ll listen’. Three staff records were inspected and demonstrated the organisation has robust recruitment practices. All records included a photograph, an application form, two written references, copies of identity, a Protection of Vulnerable Adults (PoVA first) check and a Criminal records Bureau Check (CRB). Inspection of records and discussion with the team of staff revealed that training had been received for Infection Control, Moving and Handling, managing complex behaviour, Health and Safety and Crisis Intervention. Staff reported that one support staff has completed training to become a Moving and Handling trainer, and delivers this training and support to all the team, including safe use of equipment. Staff stated they valued this opportunity to develop their skills in particular areas of training. Members of the team commented that it was more beneficial having a trained support staff, who worked with the team on a daily basis having this knowledge. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 36, 37, 39, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has a clear understanding of the key principles and focus of the service. An application to begin the fit person process is to be submitted. People who use the service benefit from a professional management approach, whereby staff skills are promoted and personal achievements recognised. EVIDENCE: Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 24 The home has been without a manager since January 2006. This is a serious concern to the Commission, as the Care Standards Act 2000 clearly records the need for a registered service to have a registered manager. The service now has a manager in post, and it is required that they apply for a Criminal Records Bureau Check with the Commission, and upon satisfactory clearance submit an application to begin the Fit Person Process. It is evident from observation and discussion with staff that the manager is extremely enthusiastic and committed to providing a good service. Through discussion, the manager demonstrated and excellent knowledge of how to manage the service, the role of the Commission and Inspecting for Better Lives. The manager has completed training for the Mental Capacity Act 2005 and stated the implications of the Act were being considered, and he will play a major role in the development of the service and support to staff during the implementation of the Act. Staff commented they feel valued and part of a supportive team and would have no hesitation approaching the manager who is supportive and recognises personal achievement. Prior to the Inspection, the manager completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. The AQAA was completed to a good standard and related to the National Minimum Standards for each outcome area. Evidence within the AQAA was sampled and found to be accurate. The manager recorded that all maintenance work, annual checks, mandatory training, testing of equipment and regular fire drills are undertaken. The Fire records were inspecting and found to be up to date. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 3 2 3 X X X 3 X Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 4 (1)(2) Requirement Timescale for action 19/01/08 2 YA1 5 (1)(2) To review the Statement of Purpose to reflect the registration review and removal of conditions to ensure the guide reflects the service provided including who the home is able to accommodate To review the Service User Guide 19/01/08 to ensure that details relating to the fees payable are included to ensure that people who use the service have all information relating to their terms and conditions of occupancy. Plans of care need to be 19/02/08 reviewed to ensure they are person-centred and reflect individual’s needs. The plans are to evidence service user involvement and agreement to any restriction The corridor to rooms 30-32 has 19/12/07 an unpleasant odour. This needs to be investigated and appropriate action to resolve this must be taken to ensure people have a suitable environment to live in. DS0000039550.V341666.R01.S.doc Version 5.2 3 YA6 15 (1)(2) 4. YA24 16 (2)(k) Woodcross Mental Nursing Home (Highfields) Page 27 5 YA37 8 (1) The manager must submit an application to begin the Fit person process following suitable clearance from the Criminal Records Bureau. The home must have a registered manager in place. This requirement has not been met from the last visit on 21/07/06. 19/01/08 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. 2 Refer to Standard YA22 YA33 Good Practice Recommendations To record verbal complaints and concerns to demonstrate how the service responds to individuals views. To record the actual hours worked by all staff in the home including the manager to demonstrate the staffing and support provided. Woodcross Mental Nursing Home (Highfields) DS0000039550.V341666.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 1st Floor Ladywood House 45-46 Stephenson Street BIRMINGHAM B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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