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Inspection on 21/07/06 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 21st July 2006.

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

The inspector 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

The home is very well presented to prospective clients both in general appearance and in the excellent sources of information provided to enable prospective service users to decide if the home will suit them. Arrangements for pre-admission visits and trial periods are seen by service users and staff as very helpful to settling in to the home. The home has very good assessment procedures and care planning systems in place and service users are confident that their personal needs are understood and can be met. The staff are seen to have excellent relationships with the residents interacting naturally, with empathy and deliver care as the person wishes, achieving a high level of satisfaction and sense of wellbeing amongst the residents. The home gives a high priority to obtaining service users views and demonstrate a commitment and flexibility in meeting the wishes of individuals. The property is well maintained and kept in good decorative order and in a clean odour free state. The home demonstrates a good commitment to staff training and provide for appropriate levels of formal supervision.

What has improved since the last inspection?

The position of activities organiser has been replaced and continuity of therapeutic and leisure activities are being provided. As part of the quality assurance programme a survey of service users views was undertaken during June and an action plan developed in response to the findingsAs part of the promotion of good infection control practice staff have received training and hot water at staff hand wash outlets has been controlled to a safe temperature to promote good hand washing practice. The manager has since appointment re-instigated staff supervisions and delegated responsibilities to senior staff to undertake a programme that will ensure the minimum of six one to one supervisions are undertaken over each 12 month period.

What the care home could do better:

The number of staff holding an NVQ qualification has been eroded by staff leaving, enrolment of new staff to the course has happened and it is anticipated that the standard will be met during the year. It was noted that service users have a terms and conditions document on file that relates to the previous ownership and this should be reviewed to ensure the current company are able to meet these, it was also apparent that the contracts held from the funding authorities were not available at the home and it could not be ascertained that the detail of the contract are being met. The staff receive basic first aid training as part of their mandatory training but none have undertaken the certificated course. The home requires to ensure sufficient staff receive this training to provide first aid cover at all times, reliance on nurses without specific training is no longer acceptable.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Woodcross Mental Nursing Home (Highfields) Woodcross Mental Nursing Home 23 Reeves Street Bloxwich Walsall West Midlands WS3 2DG Lead Inspector Richard Eaves Key Unannounced Inspection 21st July 2006 08:30 Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.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.V303398.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 and 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.V303398.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 Southern Cross Healthcare Centres Limited 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.V303398.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 6th March 2006 Brief Description of the Service: Woodcross Nursing Home is registered for adults with enduring mental ill health. It is a purpose built two storey building owned by Southern Cross Healthcare Centres Limited. The home is located near the centre of Bloxwich with local bus services, shops and other amenities close by. The home recently completed a programme of refurbishment and decoration and is furnished to a high standard. A number of double bedrooms have been altered to single occupancy rooms, which has resulted in a reduction in the number of places available. The home is well managed and the staff team work hard to maintain a therapeutic, rehabilitative approach to care. Fees for the home range from £392 to £900. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: the action plans submitted by the home to the inspections during September 2005 and March 2006, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire, comment card responses from service users and records held at the home. The inspection involved a full tour of the property including, a number of bedrooms, communal rooms and service areas and provided an opportunity to speak with most of the service users. What the service does well: What has improved since the last inspection? The position of activities organiser has been replaced and continuity of therapeutic and leisure activities are being provided. As part of the quality assurance programme a survey of service users views was undertaken during June and an action plan developed in response to the findings. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 6 As part of the promotion of good infection control practice staff have received training and hot water at staff hand wash outlets has been controlled to a safe temperature to promote good hand washing practice. The manager has since appointment re-instigated staff supervisions and delegated responsibilities to senior staff to undertake a programme that will ensure the minimum of six one to one supervisions are undertaken over each 12 month period. 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. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The homes statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home, this is confirmed at admission by the issue of local terms and conditions, the lack of a copy of the contract between the funding authority and the company means that the full details cannot be assured. Skilled and experienced staff use a comprehensive range of assessment tools, which means that service users needs are thoroughly assessed to ensure that care needs will be met and confirmation of this is given. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions that are right for them. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 9 EVIDENCE: The Statement of Purpose and Service users Guide are currently subject to review since the appointment of a new manager and to be reissued following completion of the registration process for the manager, these documents are useful, informative and provided in each service users bedroom. The homes senior staff undertake extensive pre-admission client enquiry/assessments of prospective service users using a research based assessment tool including in depth mental health assessments and confirmation that the home will be suitable to meet the assessed needs is provide prior to admission. A sample of residents files were inspected and show the assessment process to be thorough, including all activities of daily living and an extensive range of risk assessments, all assessments are subject to monthly review. The file documents information of the service user or representatives involvement in the assessment process. Pre-admission visits, including overnight stays are considered essential in establishing the suitability of the prospective service user for the home and acceptance by other service users. The home currently issues a terms and conditions document, which was issued by the previous company and requires to be up dated. This document makes no reference to the contract between the funding authority and the company and cannot be checked that individual authority requirements are being met, such as the provision of toiletries or not and other extras. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care planning at the home is good, clear and consistent, providing staff with the necessary directions of actions required, to ensure that service users care needs are fully met and health is promoted. Service users are fully involved in all aspects of life at the home and are supported to make decisions for themselves and encouraged to be as independent as possible, even though this may mean taking risks. EVIDENCE: Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 11 A sample of six service users case files, including that of a new service user, were inspected and found to contain an individualised plan of care developed from the extensive range of assessments, which covers all aspects of personal and social support, mental and physical healthcare needs. The plan is drawn up with the involvement of the service user as appropriate. The care plan for most recently admitted service user (3days), had limited risk assessments confined to those included in the integrated assessment and not showing new problems, the care plans were not signed and dated with no review date. The files for established service users demonstrate that they are supported in decision-making regarding their lives. The plan of care details any agreed restrictions on freedom and choice as a result of risk assessments and is kept under review. The case files for the elderly and other vulnerable service users had no documented care plan for responding to extremes of weather, currently a heat wave. There was evidence of staff making plenty of drinks available. The manager arranges regular service user meetings the last held during May, the minutes of which were seen and included planning leisure events and trips for over the summer, the next meeting is planned for this month. Surveys of service users views were undertaken during June and analysis and action plan implemented. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 – 17 The home provides a varied social and recreational activity programme that provides interest and pleasure for service users. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 13 Service users are enabled to get out and about in the local community and the nearby town and take responsibility for their participation in the life of the wider community. The involvement of family and friends is encouraged in agreement with the service users wishes. Meals at the home are wholesome and meet the nutritional needs of service users while providing for choice and personal taste. EVIDENCE: Currently the colleges are closed for the summer, eight service users completed courses over last year and some have indicated that they will enrol again. The homes on site therapy centre continues to assist service users to develop life skills and during the day a number were engaged in preparing their own ‘healthy option lunch’ and were happy to describe what they were doing to the inspector, one said she got a lot of satisfaction from making her own meals. Support is given to enable service users to make use of services, facilities and activities available in the local community; this is a recognised part of staff duties. Many attend the a local service users club for regular evening entertainments and activities. The process of attending these activities also forms part of the service users therapeutic programme. The activities programme includes a range of activities within and outside of the home, these include attendance at a fitness group, gardening and swimming. A number of outings are planned for over the summer months. At this time no holidays have been planned for this year. The home has access to its own transport and local public transport is easily accessible. Individual choice is promoted as far as possible for this particular client group and staff were seen to interact with service users with respect and kindness. The observation panels in bedrooms doors have been obscured with curtains to promote privacy. Subject to individual assessment service users have a key to their bedroom and access the front door via a coded keypad, many service users were observed to come and go freely. There is a four-week rotational menu in operation, which includes choice at the three main meals; supper is included on the menu. Lunch was served during the inspection and the meal appeared appetising, tasty and nutritious and was Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 14 enjoyed by all. Past surveys of satisfaction have shown a good deal of satisfaction with the meals. In conversation with service users over the lunch period they were very positive about the meals, some saying the food is great and plenty to eat while others were less effusive they said the food was alright. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users are assisted to maximise their independence and control over their lives and staff respect their privacy and dignity and give support to achieve this. Healthcare needs are well documented and are compiled with the input of the individual service user. The care plans give clear directions to ensure that service users’ healthcare needs are assessed, recognised and addressed. Arrangements for the administration of medication are good and ensure service users medication needs will be safely met. EVIDENCE: Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 16 The home routines are flexible although service users are encouraged to accommodate meal times and medication regimes within their personal routines they are generally encouraged to make independent choices. Every shift is led by a psychiatric nurse to meet the day to day mental health nursing needs and each service user has allocated a key worker to provide consistency of approach to meeting the individuals wishes in respect of maintaining their routines and choices. During the inspection it was noted that all service users were achieving good standards of personal hygiene and appearance. Service users have their physical, emotional and mental health needs met and the care plans evidence general practitioner and other health care professionals input. The home uses the Boots monitored dosage system for most tablet form medications, and the chemist visits regularly to audit the practices at the home. Arrangements for the receipt, recording, storage, administration and disposal of medicines comply with the homes policy and this standard and a contract is in place for the disposal of pharmaceutical waste. None of the current service users are assessed as able to self administer or control their own medications. The manager confirmed that service users are all subject to regular medical review of their medication regimen. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes to an environment that is safe from abuse. EVIDENCE: The concerns/complaints policy and procedure has been kept under review and promoted through the service user guide and notice. The home has policies in keeping with national guidance and staff receive training in adult protection procedures provided by Social Services. There is one complaint currently being addressed and is at stage two of the company policy. The home has available details of an advocacy service ‘Care Aware’ which offer an independent source of support for service users. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home provides a good standard of décor, furnishings and managed services providing a safe environment, a comfortable, attractive, and homely place in which to live. The home is clean and hygienic and free from odours. EVIDENCE: The home is located near the town centre of Bloxwich, local bus services, shops and other amenities are close by. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 19 The inspection took place on a warm summer day and the garden and courtyard areas were well used by the service users with plenty of garden furniture with a gazebo providing shade A programme of refurbishment of the whole premises has recently been completed and the home is decorated and furnished to a high standard. The main lounge furniture has been renewed since the previous inspection and the smoking lounge repainted. The premises were seen to be safe, comfortable, clean and hygienic and free from odour on the day of inspection. A maintenance programme is in place with records of regular monitoring and servicing. The laundry has suitable procedures in place for dealing with soiled linen and washing machines have appropriate programmes for sluicing and disinfection, it is planned to refit the laundry during this financial year. Laundry and domestic staff are employed in sufficient numbers to ensure standards related to hygiene are met. A sluice disinfector is available on the ground floor and has been fitted with a smoke detector. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 – 36 Staff are enthusiastic, sufficient in numbers, supportive and committed to maximising the service users quality of life. The lack of training to NVQ level means that staff competency cannot be assured. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: Normal staffing levels for the daytime are for 2 mental health nurses, 4 or 5 carers and an activity co-ordinator and a nurse and 3 carers overnight, a second nurse occasionally takes up a carer position, the manager is supernumerary to these numbers. Nursing and care staff receive training and updates in mental health conditions that prepares them to have the skills and Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 21 knowledge to meet service user needs and are rostered in sufficient numbers both during the day and at night. A number of NVQ qualified staff have left and training has been unable to keep pace and the 50 standard for NVQ staff is not met. Mandatory training requirements in fire safety, food hygiene, manual handling, health and safety including COSHH are met. Sufficient ancillary staff are deployed for catering, housekeeping and laundry to achieve good standards, the maintenance position is currently vacant and support is provided from another home in the company. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 &42 The acting manager is supported well by the staff, who demonstrate a good awareness of their roles and responsibility and identify with the leadership that ensures the team provide for the service users needs. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 23 EVIDENCE: The recently appointed manager has requested an application to apply for registration. The manager continues to maintain a good service, with high morale amongst the staff met during the inspection. The service undertakes extensive audits of the services provided which most often includes a formal survey of service users views, this aspect of quality assurance has not been undertaken in recent months. A full range of servicing, maintenance and regular monitoring of services and equipment is undertaken and staff receive training in health and safety and first aid, however none of the staff hold certificated first aid qualification. Records of all accidents are recorded, using data protection compliant documentation and reported as necessary, an audit of all accidents is undertaken on a quarterly basis. The accident records require to be filed in accordance with the guidance provided in the accident book. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 3 3 4 3 5 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 2 38 X 39 3 40 X 41 X 42 2 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 25 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 YA32 Regulation 18(1)(c) Requirement The responsible person will provide sufficient access to NVQ training to ensure 50 of carers achieve level 2. Previous timescale of 30/06/06 not met. The responsible person must make available for inspection the contract between the funding authority and the company for each service user. The terms and conditions should be revised to show the current company. The manager must make application to be registered. The responsible person must provide training in first-aid at certificate level in sufficient numbers to provide cover for all shifts. The responsible person must maintain accident records in accordance with guidance to meet the Data Protection Act requirements. Timescale for action 31/12/06 2. YA5 5(1) 31/10/06 3. 4. YA37 YA42 9(2) 13(4)(c) 31/08/06 31/12/06 5. YA42 17(1)(b) 31/08/06 Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 26 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 YA6 Good Practice Recommendations The home must assess the vulnerability of service users to extremes of weather and provide care plans as appropriate. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 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. Woodcross Mental Nursing Home (Highfields) DS0000039550.V303398.R01.S.doc Version 5.2 Page 28 - 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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