Inspection on 30/06/06 for Woodfalls Care Home

This inspection was carried out on 30th June 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Woodfalls Care Home 23/01/08

Woodfalls Care Home 27/10/05

Woodfalls Care Home 24/05/05

Woodfalls Care Home 13/01/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodfalls Care Home Vale Road Woodfalls Salisbury Wiltshire SP5 2LT Lead Inspector Thomas Webber Unannounced Inspection 30th June 2006 09:15 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 Woodfalls Care Home DS0000062541.V301488.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. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodfalls Care Home Address Vale Road Woodfalls Salisbury Wiltshire SP5 2LT 01725 511226 01725 513561 woodfallscarehome@virgin.net 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) Woodfalls Care Ltd Mrs Lorraine Hill Care Home 20 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (20) of places Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: Woodfalls Care Home is a private residential care home offering accommodation and personal care to 20 service users over the age of 65 who require care primarily through old age, ten of whom have been diagnosed with dementia. The home is registered with Woodfalls Care Home Ltd and the registered manager is Mrs Lorraine Hill. The home is a detached property and is located in the small village of Woodfalls near Salisbury. The home provides one shared and seventeen single bedrooms, which are located on the ground and first floor levels and are accessed by a stair lift. There is a small, enclosed garden to the rear and side of the property. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted over a period of two days on 30th June and 5th July 2006 from 09:15 to 16:00 and 09:25 to 16:45 respectively. The judgements contained in this report have been made from evidence gathered during the inspection, which included a tour of the premises and takes into account the views and experiences of twelve of the eighteen residents in situ which were sought on an individual and group basis. The views of two members of care staff, three ancillary staff as well as the manager and deputy manager were also sought. The views of one resident’s relative and two district nurses were also obtained. Comment cards were received from ten residents’ relatives, the exercise instructor and ten members of staff. Thirty two of the thirty eight Standards were assessed on this occasion which included examining records, staffing, care practices, systems, policies and procedures and feedback was provided throughout the inspection. What the service does well: Opportunities are available for prospective residents and their families to visit the home, prior to admission, to assess the quality of facilities and suitability of the home. Residents’ health care needs are being suitably met. Appropriate procedures have been established which recognises the rights for residents to be responsible for their own medication, where capable. Resident’s privacy and dignity are respected at all times. Residents’ social, recreational, and spiritual needs are suitably catered for and they maintain contact with their families and friends in accordance with their individual circumstances. Residents, within their capabilities, can exercise personal autonomy and choice. Residents receive a varied, appealing and balanced diet and meals are taken in a congenial and relaxed setting. Residents spoken to commented very positively about the quality and quantity of food provided, stating they receive plenty of food and are offered a choice. Residents are provided with appropriate information on how to complain and they felt confident that any complaints would be listened to and acted upon. Since the last inspection, the home has received two concerns which have been satisfactorily resolved by the home. Appropriate procedures have been established to protect the residents from abuse and staff are aware of them. The health, safety and welfare of the residents and staff are, in the main, promoted and protected. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 6 The location and layout of the home is suitable for its stated purpose. All parts of the home are accessible, safe and well maintained to meet the residents’ individual and collective needs. The home continues to be maintained to a good standard being clean, tidy, comfortable and suitably furnished. The standard of decoration varies. The home provides sufficient and suitable toilets, bathrooms and communal facilities. The sizes of bedrooms for residents’ use are suitable to meet their needs and residents have personalised them to their individual wishes. The home provides appropriate laundry facilities to meet the needs of the residents. Residents commented very favourably about the standard and cleanliness of their accommodation, stating that their bedrooms are comfortable, and are kept clean and tidy. They also commented very favourably about the laundry arrangements in place, stating that their clothing is returned in good condition. The home is run and managed by persons who are appropriately qualified and have sufficient experience within the care setting. The home is run in the best interests of the residents where opportunities exist for them to contribute on a regular basis. The home ensures that there are sufficient numbers of staff on duty at all times to meet the needs of the residents. The staff team collectively have a range of experience to meet the needs of the residents and the home is actively working towards achieving a trained workforce, which includes staff completing NVQ as well as specialist training. Staff were observed to carry out their duties in a caring and attentive manner where relaxed, warm and positive relationships exist between the staff and residents. Residents’ relatives surveyed commented that they are kept informed of important matters affecting their relatives, they are consulted if their relatives are not able to make decisions, there are always sufficient staff on duty and they are satisfied with the overall care provided. Residents’ relatives specific comments described the home as being friendly, not too big or institutionalised, the care is of the highest standard where residents are extremely well looked after by staff who are friendly, attentive, caring, dedicated and are always welcoming and encourage visits from family members. The exercise teacher who visits the home on a regular basis described it as being an example of ‘best practice’ in everything she has seen. Due to the excellent staff, the exercise classes for the residents run smoothly. Two district nurses spoken to also commented positively about the care provided. What has improved since the last inspection? Residents are now provided with a copy of the home’s written contract and have been fully assessed by the home, prior to admission, to ensure that their needs can be met. Some improvements have been made to residents’ living environment. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 and 6 This judgement has been made from evidence gathered both during and before the visit to this service. Residents are provided with a copy of the home’s written contract and have been fully assessed by the home, prior to admission, to ensure that their needs can be met. Opportunities are available for prospective residents and their families to visit the home, prior to admission, to assess the quality of facilities and suitability of the home. Quality in this outcome area is good. EVIDENCE: All residents would normally be provided with a copy of the home’s contract and a copy of the placing authority’s terms and conditions would also be given to those residents who are funded by social services. Copies of the home’s contract are waiting to be signed and returned in respect to the two most recent residents admitted to the home. However, a spot check of seven other residents’ files confirmed that signed contracts were in place. Management from the home would normally meet with all prospective residents prior to admission and undertake their own assessment. In addition, the home would also normally obtain a copy of the resident’s community care Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 10 assessment or the equivalent prior to admission for those residents funded by social services. Documentary evidence was available to confirm that staff had assessed the two most recent residents admitted which involved discussions with the residents, hospital staff and the family of one of the residents. The manager reported that prospective residents are informed verbally, at the assessment process, if the home is able to meet their needs. However, the manager has agreed to formalise this process by following this up in writing As part of the admission process, prospective residents and their families are encouraged to visit the home prior to admission. In respect to the two most recent residents admitted to the home, neither of them made any pre-visits to the home by choice. However, the family of one resident made visits to the home on two separate occasions and the other resident knew the staff well and the facilities provided as she used to visit friends who previously lived at the home. The home does not provide intermediate care, therefore, this Standard is not applicable. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 This judgement has been made from evidence gathered both during and before the visit to this service. Residents are provided with a care plan and their health care needs are being suitably met. Appropriate procedures have been established which recognises the rights for residents to be responsible for their own medication, where capable. Medication procedures are not always being appropriately followed. Resident’s privacy and dignity are respected at all times. Quality in this outcome area is good. EVIDENCE: All residents have been provided with a long term care plan/assessment. Residents’ daily case notes are regularly recorded and are informative. Other assessments such as manual handling, pressure sore and nutritional are only completed where specific risks have been identified. It was noticed that in relation to the two most recent residents admitted, short term care plans and risk assessments had not been completed. However, individual risk assessments, in particular in relation to falls, are in the process of being completed in respect of all residents. Discussions with some residents confirmed that their health care needs are being suitably met. All residents admitted to the home are transferred and registered with one surgery. The majority of appointments undertaken by the Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 12 GP and district nurse are held within the home where residents normally receive any treatment in the privacy of their bedrooms. Residents confirmed they access other health care services such as dental, opticians, chiropody and hearing, as and when required and this was also confirmed within their various records held by the home. Appropriate aids are provided for those residents who require them for incontinence and mobility. The home has established an appropriate medication policy and procedure, which confirms and recognises the rights of residents to maintain control over their medication for those residents who are deemed capable following an assessment. Suitable and lockable facilities have been provided within residents’ bedrooms for this purpose. On the day of inspection none of the residents were self-medicating. Only one resident had been assessed as being capable but had chosen not to. The manager has agreed to record residents’ ability and preference to self-medicate on the initial assessment form. The outcome of the GP’s assessment, with regard to each resident’s ability to selfmedicate, is also recorded on the MAR sheet. The manager has also developed a form for this purpose as agreed at the previous inspection. Care staff do not administer medication to residents unless they have completed the recognised “Safe Handling of Medication” course. The manager reported that the majority of care staff have completed this course which was also confirmed by their training records. The home uses the Lloyds monitored dosage system for the recording of medication administered. Evidence was available to confirm that residents’ drug sheets are being appropriately maintained. However, there are still occasions where the practice of (hand written) medication records received into the home not always being initialled by two members of staff. In addition the quantity of medication received is not always being recorded. These deficiencies in practice were brought to the attention of the manager. The manager reported that the PCT pharmacist visited the home on 30th January 2006 to review the residents’ medication. Her findings are reported to the residents’ GPs. The manager reported that no areas of concern were raised as a result of her visit. In addition, the manager also reported that the Lloyds pharmacist also visited the home on 24th December 2005 to review the receipt, recording, storage, handling, administration and disposal of medication. Again, no concerns were identified. Comments are contained within the home’s service users’ guide to confirm that service users are treated with respect and their right to privacy is upheld. Copies of the home’s core values which refer to privacy, dignity, choice, independency and fulfilment are displayed in the lobby entrance. Observations and discussions with some residents confirmed that all but two residents are provided with their own bedrooms where they can conduct all their personal affairs in complete privacy, including medical examinations and treatment. Residents can choose where to spend their time and who and Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 13 where to see any visitors. Residents have access to a mobile phone, which they can use in the complete privacy of their bedrooms and they are not charged for any calls made when using this facility. Alternatively, residents can have a telephone installed in their bedrooms and a few of them have availed themselves of this facility. Residents’ mail is given directly to them unopened. However, staff assistance is provided to those residents who are unable to deal with their mail. Woodfalls Care Home DS0000062541.V301488.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ social, recreational, and spiritual needs are suitably catered for. Residents maintain contact with their families, friends and relatives in accordance with their preferences. Residents, within their capabilities, can exercise personal autonomy and choice. Residents receive a varied, appealing and balanced diet and meals are taken in a congenial and relaxed setting. Quality in this outcome area is good. EVIDENCE: It was apparent from observations and discussions with residents that they can choose where and how to spend their time, including rising and going to bed. Residents have the opportunity to pursue their own individual interests and hobbies as well as being able to participate in the range of organised activities and outings arranged by the home, should they so wish. The manager and some comments received by staff as part of a survey carried out by the Commission acknowledged that the responsibilities and numbers of staff sometimes restricts the level of activities provided. However, there has been an increase in the provision of visiting entertainers and outings being provided due to the increase use of the mini bus. The religious needs of the residents are well catered for from various denominations. The mobile library service visits the home weekly and there is also a twice weekly visiting hairdressing service available to the residents. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 15 The home has established a policy of open visiting by residents’ families and friends who can also phone at any time. This policy is confirmed within the home’s service users’ guide and a copy of its aims and objectives, which reenforces this, is displayed within the lobby entrance of the home. Comment cards received by the Commission from residents’ relatives also confirmed that they are made welcome at any time and they are greeted at the front door by staff and they can their relatives in private. Some residents spoken to confirmed that they can choose where they entertain their visitors either in the privacy and comfort of their bedrooms or in one of the communal rooms available. Observations and discussions with some residents confirmed that they can exercise personal autonomy and choice within their individual capabilities. Residents can and have brought items of furniture and personal possessions to make their bedrooms more homely, they can choose how and where to spend their time, where to eat, and what activities to participate in. Residents, who are capable, could also handle their own financial affairs in the privacy of their own bedrooms. The home provides a satisfactory and varied four weekly menu, which provides residents with a choice at all mealtimes including a cooked meal at breakfast, Friday to Sunday, for those residents who wish it. The choice for the main meal currently consists of a salad, although this will be changed to a cooked meal for the winter season. The manager and cook confirmed that the menu is in the process of being reviewed in consultation with the residents. Residents can choose where to eat their meals, although they tend to use the dining areas for their main meal. Observation of the main meal confirmed that it was conducted in a relaxed and congenial manner where staff assistance was provided to those residents who required it. Residents spoken to commented very positively about the quality and quantity of food provided, stating they receive plenty of food and are offered a choice. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 This judgement has been made from evidence gathered both during and before the visit to this service. Residents are provided with appropriate information on how to complain and they felt confident that any complaints would be listened to and acted upon. Appropriate procedures have been established to protect the residents from abuse and staff are aware of them. Quality in this outcome area is good. EVIDENCE: Residents are provided with a copy of the home’s complaints procedure, which is contained within the home’s service users’ guide and is located in all residents’ bedrooms. The complaints procedure specifies how and who would deal with any complaints. Residents and relatives spoken to commented that they had no complaints or concerns and if they did, they felt confident in discussing any issues with the manager and staff who would listen and act upon them accordingly. Since the last inspection, the home has received two concerns which have been satisfactorily resolved by the home, however, the home needs to ensure that the complaints/concerns monitoring form is always completed in sufficient detail and contains any supporting evidence. Appropriate policies and procedures are in place for responding to suspicion or evidence of abuse. Copies of the full and shortened version of the Wiltshire and Swindon Vulnerable Adults procedures have been obtained which are in line with the Department of Health Guidance “No Secrets” document. Copies of the shortened version of this document have been distributed to all staff and staff comment cards received by the Commission and staff spoken to confirmed that they are aware of the adult protection procedures. New staff Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 17 cover the issue of abuse during their induction programme and the manager reported that all staff have received Abuse training. Staff spoken to and staff training records checked confirmed this. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 This judgement has been made from evidence gathered both during and before the visit to this service. The location and layout of the home is suitable for its stated purpose. All parts of the home are accessible, safe and well maintained to meet the residents’ individual and collective needs. The home continues to be maintained to a good standard being clean, tidy, comfortable and suitably furnished. The standard of decoration varies. The home provides sufficient and suitable toilets, bathrooms and communal facilities. However, there are a number of areas within the home which require improvement. The sizes of bedrooms for residents’ use are suitable to meet their needs and residents have personalised them to their individual wishes. The home provides appropriate laundry facilities to meet the needs of the residents. Quality in this outcome area is good. EVIDENCE: The home continues to be maintained to a good standard and offers suitable heating and ventilation. During the course of the inspection some concerns were raised about the level of lighting to some areas of the building, particularly to some bedrooms and corridors. This can be achieved by the reWoodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 19 hanging of some light shades and the change to the wattage of some light bulbs. The standard of decoration within the home varies with some being maintained to a good standard and other parts in need of redecoration. Further concerns were raised with regard to other aspects of the environment, which the providers have subsequently confirmed that these will be addressed on the completion of the building works. Concerns were also raised with regard to the need to establish appropriate storage facilities, as the existing facilities are inadequate. In addition, concern was also expressed about the level of maintenance to the home. However, some improvements have taken place to enhance the residents’ living environment and these include the redecoration and re-carpeting to some bedrooms and the replacements of the dishwasher, two washing machines and tumble dryers. The home provides sufficient communal space for the current number of residents accommodated. These consist of a lounge/diner, a conservatory, a small sitting room and a seating area to the front entrance hall. All these areas are comfortable and furnished to a good standard. However, there are plans to extend the number of places from twenty to twenty-four and the proprietors were advised to ensure that suitable and additional communal space is provided which will meet the needs of all the residents accommodated. The home has an enclosed garden to the rear and side of the property, which is suitably maintained. The garden contains various seating areas and is appreciated and used by the residents, weather permitting. There is a range of toilet, shower and bathroom facilities which are located within close proximity to residents’ bedrooms and the communal rooms. There are two assisted bathrooms and a shower room which meet the current needs of the residents. The bathroom and toilet facilities are provided with appropriate locks. On the days of inspection, one of the toilets to the first floor was not flushing properly, however, this has subsequently been repaired. Three of the bedrooms are provided with en-suite facilities. A stair lift has been installed which services the first floor, however, the proprietors have obtained planning permission to install a passenger lift that would enable residents to access the first floor independently. Mobility aids, such as zimmer frames, have been provided to those residents who require them. All rooms are fitted with a call bell system which residents can use to summon staff assistance if required. The home provides seventeen single and one shared bedroom, three of which provide en-suite facilities. Only one single bedroom is marginally undersized. Residents’ bedrooms are light and airy and colour co-ordinated. Residents’ bedrooms are suitably furnished and equipped to ensure comfort, and privacy. However, as stated in Standard 19, improvements need to be made to ensure that all residents’ bedrooms are provided with appropriate levels of lighting to meet their assessed needs. Residents can and have brought items of furniture and personal possessions to make them more homely with residents having Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 20 personalised their bedrooms to their individual wishes. All bedroom doors have been fitted with locks and residents’ bedrooms have been provided with a lockable storage space. A privacy screen is available and is used as required for the shared bedroom. Residents commented very favourably about the standard and cleanliness of their accommodation, stating that their bedrooms are comfortable, and are kept clean and tidy. Residents’ accommodation provides suitable heating and ventilation, although the level of lighting within some areas of the building could be improved. Radiator covers have been fitted for residents’ protection but the type of installation still enables residents to control the level of heating to their bedrooms through individual radiator controls. Thermostatic valves have not been fitted to the hot water taps used by residents. The home continues to be maintained to a good standard, being clean, tidy and comfortable and free from offensive odours. The laundry room is located on the ground floor and provides limited space although the facilities are adequate to meet the needs of the home. Residents’ clothing is labelled to ensure that garments are appropriately returned and residents commented very favourably about the laundry arrangements in place, stating that their clothing is returned in good condition. Care staff undertake the laundry duties with some input from the waking night staff. Strong consideration should be given to the employment of laundry staff which would free up care staff to spend more quality time with the residents, as part of the overall staffing review due to the increase in the number of residents. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 This judgement has been made from evidence gathered both during and before the visit to this service. The home ensures that there are sufficient numbers of staff on duty at all times to meet the needs of the residents. The staff team collectively have a range of experience to meet the needs of the residents and the home is actively working towards achieving a trained workforce, which includes staff completing NVQ as well as specialist training. The recruitment practices within the home still does not provide a robust system to ensure the protection of residents. Quality in this outcome area is good. EVIDENCE: The deployment of staff ensures that there are three members of care staff on duty throughout the waking day with two members of waking night staff on duty each night. These staffing levels do not include those hours worked by the manager and various ancillary staff employed. The deputy manager reported that she has had to occasionally use agency staff to maintain the required staffing levels, although existing staff have normally covered any gaps. Residents spoken to commented very positively about the care provided by the staff, stating that they are very well cared for and the staff are excellent. Staff were observed to carry out their duties in a caring and attentive manner where relaxed, warm and positive relationships exist between the staff and residents. Residents’ relatives surveyed commented that they are kept informed of important matters affecting their relatives, they are consulted if their relatives are not able to make decisions, there are always sufficient staff on duty and Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 22 they are satisfied with the overall care provided. Residents’ relatives specific comments described the home as being friendly, not too big or institutionalised, the care is of the highest standard where residents are extremely well looked after by staff who are friendly, attentive, caring, dedicated and are always welcoming and encourage visits from family members. The exercise teacher who visits the home on a regular basis described it as being an example of ‘best practice’ in everything she has seen. Due to the excellent staff, the exercise classes for the residents run smoothly. Two district nurses spoken to also commented positively about the care provided. The staff team have a variety of experience in the care profession. The home has worked well to achieve approximately 80 of the staff team being trained at NVQ level 2 in care. Since the last inspection, no care staff have been employed. However, the home has employed a housekeeper and all satisfactory checks had been carried out apart from at least obtaining a POVA first check prior to her employment. Although the manager reported that the housekeeper undertook her induction and was supervised at all times whilst waiting for the POVA first check, she acknowledged that she should not have employed her until it had been received. The manager stated that had she been employed as a member of care staff, she would not have started her until she had at least received a copy of her POVA first check. The home has established an appropriate induction programme, which is completed by all new staff employed and staff are also provided with a staff handbook. The aim of the home is to provide all mandatory training within six months of staff being employed and staff would then be considered for NVQ training. Certificates of training undertaken by staff were clearly evident in their respective staff training files. Staff training records show a high level of training has been undertaken by staff, including both mandatory and specialist training. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 This judgement has been made from evidence gathered both during and before the visit to this service. The home is run and managed by persons who are appropriately qualified and have sufficient experience within the care setting. The home is run in the best interests of the residents where opportunities exist for them to contribute on a regular basis. The home no longer looks after money on behalf of the residents. Staff are being supervised, although the frequency is less clear. The health, safety and welfare of the residents and staff are promoted and protected, apart from the area of fire prevention. Quality in this outcome area is good. EVIDENCE: The manager has appropriate management and supervisory experience in the relevant care setting she manages. She has sucessfully completed the NVQ level 4 and the Registered Managers’ Award and undertakes periodic training to update her skills and knowledge. Since the last inspection, the manager has achieved the NVQ Assessor’s award and in conjuction with an outside verifyer Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 24 has assisted a number of staff through their NVQ 2. The manager is supported in the day to day management of the home by her deputy manager who has also completed the NVQ level 4 and has considerable experience in the care profession. She also undertakes periodic training to update her skills and knowledge. Staff comment cards received and discussions with staff indicate that residents benefit from an open, positive and inclusive atmosphere within the home where the manager and deputy manager communicate with a clear sense of direction and leadership. Staff morale is good and staff commented very positively about the level of support and the very positive and relaxed atmosphere within the home where they work very well as a team with each other’s roles being respected. Staff also commented that both the manager and deputy manager are very approachable and they can discuss any issues with them. Regular staff meetings and daily hand over meetings occur which ensure that staff are kept informed. Staff appear happy with the training opportunities available to them. Likewise, residents feel able to discuss any issues or concerns with the manager and/or staff and feel these would be suitably dealt with. As part of the home’s quality assurance process, the home has developed questionnaires for residents, their relatives and other professionals to ascertain their views on the care and services provided. In addition, residents are able to contribute to the running of the home by verbally expressing their views at residents’ meetings. Individual sessions between residents and their keyworkers also take place. The manager and deputy manager also monitor the care and services provided on a daily basis. The home continues not to manage residents’ money, preferring to bill their relatives or representative for any expenditure accrued. Therefore Standard 35 is not applicable. There are a range of mechanisms in place for the manager to both brief and receive feedback from staff in order to monitor the standard of care and services provided to the residents. These include daily handover meetings, regular staff meetings, informal and formal staff supervision. However, the manager acknowledged that the level and frequency of formal one to one supervision needs to be reviewed. Six of the ten staff surveyed and five spoken to confirmed that they have received formal one to one supervision. A supervision programme has been established to ensure that all staff receive regular supervision. The home continues to promote the health, safety and welfare of both residents and staff. A health and safety policy statement has been established and staff have received health and safety training. A health and safety officer from Citation PlC is employed by the proprietor who visited the home in October 2005 and has subsequently sent a copy of the report to the home. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 25 Some minor inprovements where identified which included the need to complete a health and safety risk assessment for the premises. The manager reported that this is currently being undertaken. All first floor windows are fitted with restrictors. However, a continuing cause for concern relates to aspects of fire prevention. These include the need to ensure that the date is recorded to denote when staff have received fire instruction and staff need to receive fire instruction on a quarterly basis. Although it was acknowledged that three fire drills had taken place within the last two months, a programme of quarterly drills now need to be established. The fire alarm system also needs to be serviced on a quarterly basis and not twice yearly as records indicate. A fire officer is due to provide fire training to staff in August 2006. In response to the deificiencies the manager will ensure that staff are provided with fire training by video, questionnaires and will incorporate fire instruction as part of the fire drills. Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X N/A 2 X 2 Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13(2) Timescale for action The registered individuals must 07/08/06 ensure that quantity of all (hand written) medication records received into the home are recorded and always initialled by two members of staff. (Previous timescale of 21/11/05 was not met and this timescale has been extended). The registered individuals must 30/09/06 carry out an audit to ensure that a suitable level of lighting is maintained to all areas of the building. The registered individuals must 30/09/06 ensure that all members of staff are not employed without at least obtaining a POVA first check. The registered individuals must 31/12/06 ensure that all members of staff receive regular supervision. The registered individuals must 30/09/06 evidence that all staff receive fire instruction on a quarterly basis and the date is suitably recorded, fire drills are carried out on a quarterly basis and the fire alarm system is serviced on DS0000062541.V301488.R01.S.doc Version 5.2 Page 28 Requirement 2. OP19 23(2)(p) 3. OP29 19(1)(b) 4. 5. OP36 OP38 18(2) 17(2) Woodfalls Care Home a quarterly basis. (Previous timescale of 31/03/05 and 31/12/05 were not fully met and this timescale has been extended). 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 OP16 Good Practice Recommendations The registered individuals should give strong consideration to ensuring that the complaints/concerns monitoring form is always completed in sufficient detail and contains any supporting evidence. The registered individuals should give strong consideration to establishing appropriate storage facilities for the home’s cleaning materials. 2. OP19 Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Woodfalls Care Home DS0000062541.V301488.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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