Inspection on 14/08/06 for Woodfield Grange Nursing Home

This inspection was carried out on 14th August 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 but made no statutory requirements on the home.

Other inspections for this house

Woodfield Grange Nursing Home 09/12/09

Woodfield Grange Nursing Home 28/07/09

Woodfield Grange Nursing Home 04/02/09

Woodfield Grange Nursing Home 12/08/08

Woodfield Grange Nursing Home 17/07/07

Woodfield Grange Nursing Home 07/02/06

Woodfield Grange Nursing Home 15/09/05

Woodfield Grange Nursing Home 19/01/05

Woodfield Grange Nursing Home 29/09/04

Woodfield Grange Nursing Home 23/03/04

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Larchfield Manor

Hawkhills

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Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodfield Grange Nursing Home Saddleworth Road Greetland Halifax West Yorkshire HX4 8NZ Lead Inspector Lynda Jones Unannounced Inspection 14th August 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodfield Grange Nursing Home DS0000001076.V306550.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. Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodfield Grange Nursing Home Address Saddleworth Road Greetland Halifax West Yorkshire HX4 8NZ 01422 377239 01422 311863 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) Ancyra Health Limited Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide accommodation and care for one named service user under 65 years of age. 7th February 2006 Date of last inspection Brief Description of the Service: Woodfield Grange is a care home with nursing providing accommodation and care for 36 older people. The home is situated on Saddleworth Road and is approximately ½ mile from the local shops and facilities in West Vale. There is a patio area to the front of the building where residents can sit out in good weather. There are car-parking facilities to the side of the building; the car park is on a very steep slope. Accommodation at the home is arranged over three floors. There is one very large lounge on the ground floor that is divided into two sections by the arrangement of the chairs. The dining room adjoins the lounge on the ground floor. Each floor can be accessed by passenger lift. There are 34 single bedrooms and one double bedroom. None of the bedrooms have en suite facilities. Fees for the home are currently between £339 and £432 per week. Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group, for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The main purpose of this inspection was to make sure care provided was adequate, and to assess progress on meeting any requirements or recommendations made at the last visit. This inspection was carried out by two inspectors who were at the home for one day, from 10.00am until 3.30pm. The inspection process consisted of observing care practice throughout the day and observing the lunchtime process. Discussions took place with residents, the acting manager, qualified staff, care staff and kitchen staff. A sample of care plans and other documents were examined; this took place in the lounge in the presence of residents and staff. A full tour of the building was not undertaken. One of the purposes of this visit was to check to see if any progress had been made in improving bathing facilities at the home, as residents could not use the shower and some of the baths at the time of the last inspection in February 2006. This report is based on information received from the home since the last inspection in February 2006, observation and conversation with residents and staff. In addition to the time spent in the home, time was spent preparing for this inspection. A pre inspection questionnaire was sent to the home before the visit took place. This provided useful information about Woodfield Grange, which has been used in the preparation of this report. Surveys and comment cards were sent to ten residents and ten relatives asking for their views about the home. Six comment cards were received from relatives, eight surveys were returned Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 6 by residents. Some of the residents may have had support from their relatives to complete the surveys. What the service does well: What has improved since the last inspection? Complaints made to the home have been investigated promptly. The recruitment process has improved. Some parts of the home have been redecorated in recent months. The office is much better organised, information is easy to retrieve. Woodfield Grange Nursing Home DS0000001076.V306550.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. Woodfield Grange Nursing Home DS0000001076.V306550.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 Woodfield Grange Nursing Home DS0000001076.V306550.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): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are assessed before they move in to the home to make sure that their needs can be met. Information about the home for prospective residents and their families needs to be updated. EVIDENCE: The National Minimum Standards for Care Homes for Older People state that prospective service users should have the information they need to make an informed choice about where to live. The information that is available about Woodfield Grange needs to be improved. The statement of purpose, service user guide and brochure about the home are all out of date. The information about the provider, manager and staffing arrangements needs to be updated. Staff say the brochure on display in the entrance area is “years old”; it states that the home is registered with Calderdale Health Authority, which indicates that it was published before the Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 10 advent of the Commission in 2002. When asked what information was given to prospective residents and their families, staff said they usually tell people about the home and refer enquiries to the senior person on duty. Of the eight residents who completed surveys about the home, seven people said they either didn’t have a contract or they didn’t know what a contract was. The manager needs to ensure that residents and their families are familiar with contracts and with their terms and conditions of residence. A sample of care plans was examined. Evidence indicated that all residents had been assessed to make sure that their needs could be met before they moved into the home. This initial assessment then formed the basis of the care plan for each person. The home does not provide intermediate care. Woodfield Grange Nursing Home DS0000001076.V306550.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): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans could be improved to include information about residents past experiences and social needs. Health care needs are met in the main, medication records are good, wound care and personal care records need to be more accurate. Residents are not always treated with the respect and dignity they deserve, staff need to reflect on how their behaviour impacts on residents. EVIDENCE: The care planning system is still developing; the format has only been adopted in recent months. Five care plans were chosen for review and case tracking. These included plans for two residents who had recently moved into the home. There was evidence that the manager had visited all prospective residents before they moved into the home. In each case, detailed pre admission assessments had been completed containing some good information that would enable staff to develop a suitable care plan. Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 12 It was disappointing to find that very little was recorded on the care plans about the life histories of residents. There was very little information about the sort of employment people had been involved in, about their families and about the sort of interests and hobbies that people enjoyed. This needs to be addressed. Records indicate that residents have access to health care services that meet their assessed needs both within the home and in the local community. There is evidence that the home seeks professional advice on health care issues, the records show the reasons for referrals and details of the advice given by external health care providers. Some aspects of the plans require more detail, particularly in relation to personal and oral hygiene needs. It was not always possible to tell how residents preferred this aspect of their care to be delivered. From speaking to staff it is apparent that they have a good understanding of residents needs, it is likely therefore that this information is communicated verbally between members of the staff team. This should be included in the written plan. The quality of recording in relation to tissue viability needs to be improved. Some variation in the quality of recording was noted. In one of the care plans examined, the records indicated that the dressing plan was not being followed. The plan specified that a wound needed to be re-dressed every three days; the records showed that this had not taken place. The last recorded dressing had been applied on 1/8/06. On another file examined there was a reference to the treatment of a small wound; there was no dressing plan in place for staff to follow. On one other plan examined the dressing plan was up to date and the records clearly showed that it was being followed appropriately. Records indicated that the care plans were being reviewed regularly and in some cases the records showed that relatives had been present when reviews took place. All of the residents who completed surveys said they felt they received the medical support that they required; relatives indicated that they were generally satisfied with the overall care provided. Five out of six relatives felt that they were kept informed about important matters that affected their family member living at the home. One person said they expected to be informed if the doctor was needed. Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 13 Three out of six relatives did not think there were always enough staff on duty when they visited the home. One relative said she had noticed that sometimes people were left waiting after asking to go to the toilet, while staff completed other tasks. Resident’s views were mixed, generally they thought there were enough staff on duty, although they were sometimes busy and residents had to wait for things. Care practice amongst staff is variable. Some good-humoured exchanges were observed between staff and residents and residents said that staff were polite, helpful and listened to what they had to say. From observation of some practices during the course of the day however, it appears that residents are not always treated with the respect and dignity that they deserve. For example, staff were observed talking to each other across residents during the day, saying “I’m doing her” and “I’ll do him” when referring to tasks they were carrying out. When checking out the suitability of a meal for one resident, a member of staff called out to another “is he alright with one of these?” On each of these occasions the staff did not speak directly to the residents concerned. Another resident was observed being moved into the dining room with a urine filled catheter bag in full view. These practices are not respectful and need to be addressed. The home has a medication policy which is accessible to staff who administer medication. Records were examined and were found to be up to date for each resident. The records show details of all medicines received, administered and disposed of. The relevant codes were being used appropriately on the record sheets, showing for example, reasons why medication had been omitted. Woodfield Grange Nursing Home DS0000001076.V306550.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): 12,13,14,15. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is little evidence of any stimulating activity taking place at the home. The meal time arrangements need to be improved. EVIDENCE: The home has open visiting arrangements and residents know they can entertain their family and friends in their own room. Visitors to the home said they were always made to feel welcome when they called. Residents said that they could get up and go to bed when they choose. They said there is some flexibility about the time they have their breakfast but the times for other meals tends to be fixed. Residents said they tended to “fit in” with the routines of the home. Most people said they spend their time during the day sitting in one of the lounge areas, sometimes the TV is on, sometimes there is music playing. Some residents feel that their choices are sometimes curtailed because there are not always enough staff available. One person talked about often having to Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 15 wait to go to the toilet, another person said the staff were very busy and only had time to talk when they were performing personal care tasks. A resident recalled having been left on the commode on one occasion and having to use the call bell to summon staff to help her to move. She thought the staff had forgotten her. One person said she had to have a bath on a Monday morning, she said she had asked a member of staff if she could have a bath in the evening instead but she had been told that this wasn’t possible as there were not enough staff available at that time of day. The manager needs to be aware that some residents do not feel they have control over their daily routines. This must be addressed. At the time of the last inspection in February 2006 an Activities Coordinator was in post and residents commented very favourably on the range of activities on offer. Since then this post has become vacant and there is very little evidence of any stimulating activity being made available. Some residents said they missed this. In the surveys, residents were asked “are there activities arranged by the home that you can take part in”. In response, everyone said that activities take place “sometimes”. Two people who were relatively new to the home (approximately three months in residence) said they had not been involved in any activities at all. Staff said there had been some trips out during the summer but generally they had very little time during the course of their duties to devote specifically to activities. This is an area that needs to be addressed. The serving of lunch was not particularly satisfactory; the process needs to be improved. Staff said lunch is served at 12.30pm each day. At 12.15pm, sixteen people were already seated in the dining room; a few had made their own way there although the majority had been taken to the dining room by staff. Twenty-four residents had their lunch in the dining room; others had their meals in the lounge or in their own rooms. The first meals were served at 12.35; the last person was served at 1.10pm. Inspectors saw a resident trying to attract the attention of staff for several minutes at 12.50pm, to let them know that someone sharing her table had not still not been given a meal. The meals were brought out of the kitchen one at a time; as a result some residents were sat waiting while others on their table were eating their meal. No one knew what was for lunch, nothing had been written on the menu board in the dining room. Care staff did not know what was for lunch until they went to the kitchen. The meal was steak and kidney pie, mashed potatoes and green beans. One resident said she didn’t like steak and kidney pie and she was offered an alternative. This person then had to wait until an omelette was made, by which time the rest of the people on the table had finished their meals. Another resident left the pie and told staff when they collected her plate that she didn’t like too much meat, she said she had told the staff this before. Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 16 One resident who required a liquidised diet was presented with the entire meal pureed together in a bowl. Staff should be aware of what people like and do not like to eat. The residents referred to above were able to tell staff that they did not like what was on the menu, there are other people living at Woodfield Grange who are not able to articulate their views. When alternative meals are required, this should be determined before lunch is served so that people are not left waiting. Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that meets the national minimum standards and regulations. Residents indicated that they would talk to staff if they had any concerns. EVIDENCE: The home has a complaints procedure which was last reviewed in January 2006. The pre inspection questionnaire that was returned prior to the visit to the home indicates that eight complaints were made to the home within the previous twelve months. Of these, three were substantiated and five were partially substantiated after being investigated by the home. The complaints were dealt with within the twenty-eight day timescale set out in the homes procedure. Two out of six relatives said they were not aware of the complaints procedure. Two relatives said they had made a complaint, they did not give any indication as to whether their complaints had been dealt with satisfactorily, nor did they indicate when they had complained. Five out of eight resident said they knew how to make a complaint. It is not clear whether this means they were aware of the procedure or whether this means that they felt confident about raising issues informally with staff. Details Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 18 of the procedure should be included in the information that is given to all prospective residents and their relatives. All staff at the home have received adult protection training within the past twelve months. Discussions with staff indicate that they are aware of their responsibilities in this area. Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and well maintained, residents are happy with the accommodation. Existing bathroom and toilet facilities need to be improved. EVIDENCE: The home has thirty-four single bedrooms and one double room. None of the bedrooms have en suite facilities. A full tour of the building was not undertaken. One of the purposes of this visit was to check to see if any progress had been made in improving bathing facilities at the home, as residents could not use the shower and some of the baths at the time of the last inspection in February 2006. There has been no progress in improving the bathing facilities to date. Although the home may meet the National Minimum Standard in terms of the number of bathing facilities within the home, residents really have very little Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 20 choice in what they can use as many people cannot get in and out of some of the baths and the shower is unusable. The acting manager reports that there is a plan to improve all the bathing and toilet facilities throughout the home. This includes repositioning the wash hand basins in the toilets so that it is easier to get wheelchairs in and out, replacing the shower and increasing the number of assisted bathing facilities. The acting manager said that she was waiting for costings for the improvements but as yet she was unable to provide any timescales for the work to be carried out. All of the residents who completed surveys said that in their opinion the home was always clean. During the course of the visit, residents said that they were satisfied with their rooms and confirmed that they could bring personal items with them from home when they moved in. The communal areas were noted to be clean and tidy on this visit. Staff need to be reminded to close the door when the toilet on the ground floor is in use, to ensure that residents have the privacy that they deserve. Staff reported that the entrance area to the home, the office and approximately three bedrooms had recently been redecorated. A handyperson is employed at the home to deal with decorating and any repairs that are needed. Woodfield Grange Nursing Home DS0000001076.V306550.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): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment practice is good and staff records are well maintained. Staff shortages are restricting residents choices. EVIDENCE: The staffing notice issued by the previous regulatory authority shows that for between 31-35 residents there should be 6/7 members of staff on duty during the day and 3 members of staff on duty at night. One member of staff must always be a qualified nurse. Staffing levels increase for 36-40 residents when there should be 7/8 staff on duty and 3-4 at night. These staffing levels are minimal requirements and change may be required should the dependency levels of residents increase. At the time of this visit to the home, 35 people were living there. Examination of the rota showed that there had been occasions in the previous week where these levels had not been achieved. The rota revealed that during one week, in the evenings, there had been 5 staff on duty on three occasions, 4 staff on duty on three occasions and on one evening there had only been 3 staff on duty. The rota for the week following this visit revealed similar shortfalls. In the section of this report on Health and Personal Care (see standards 7-10) it has already been mentioned that some relatives did not think there were Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 22 always enough staff on duty when they visited the home. In the opinion of one relative, some people were left waiting to go to the toilet, residents also talked about staff being very busy and having to wait for things. Residents are generally satisfied that the care they receive meets their needs, but there are some times when no one is available to immediately help them. Some residents thought that their choices were sometimes restricted because staff were busy, one person gave an example of wanting to change her bath time to the evening but she was told this was not possible because there were not enough staff available. This is not acceptable. The management team must ensure that the staffing levels outlined above are adhered to in order to make sure that the needs of residents can be met; a requirement has been made in this report to this effect. At the time of this visit, the cook had been off work for some weeks. This was providing an additional strain on staff time because a member of the care team was taken off shift to cover the cook’s duties. In addition to this, the dishwasher had broken down two/three weeks previously and the temporary cook and kitchen assistant had to wash up. Staff reported that when the temporary cook was not on shift, a hot teatime meal for residents could not be provided. At the end of the visit, the acting manager was asked to take urgent action to address this situation. On a positive note, there has been a big improvement in the way staff files are ordered. The files examined contained all of the required information, information was indexed and all of the documentation was easy to follow. Woodfield Grange Nursing Home DS0000001076.V306550.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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements have been unsettled this year, there is now an acting manager who has applied to be registered. Any outstanding fire safety work needs to be completed. EVIDENCE: The last year eight months have been unsettled in terms of the management of the home. A long standing manager left the home at the end of 2005. An acting manager took up post in January 2006, staying at the home until the end of May 2006. A new acting manager is in post; she has worked at the home previously and she in the process of applying to the Commission for Social Care Inspection to the registered manager. She is a qualified nurse and she has previously been the registered manager of a home for older people. She is aware of and works Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 24 to the basic processes set out in the National Minimum Standards of Care for Older People. The Fire Safety Officer visited the home in January 2006 and provided a report with details of work that needs to be carried out in the home. Ancyra Health Limited, the registered providers, authorised this work to be carried out. However, on this visit it was not possible to ascertain whether all the work had been completed. In this report a requirement has been made for the company to provide an update on this situation. The home holds small amounts of money for approximately five residents that has been deposited by their relatives. Woodfield Grange Nursing Home DS0000001076.V306550.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 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 2 2 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Woodfield Grange Nursing Home DS0000001076.V306550.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 OP12 Regulation 16(2)(m) (n) 23 Requirement Provision must be made to provide appropriate activities that meet the requirements of residents An action plan is required, showing plans to improve the bathing facilities in the home (Previous timescale of 31/03/06 not met) The providers must ensure that there are sufficient staff on duty at all timed to meet the needs of residents. The work outlined in the Fire officer’s report of January 2006 must be completed. An update on outstanding work is required. (Previous timescale of 31/08/06 not met) Timescale for action 14/10/06 2. OP21 31/10/06 3 OP27 18 30/09/06 4. OP19 23 30/09/06 Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 27 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. 3. 4. 5. Refer to Standard OP1 OP2 Good Practice Recommendations The statement of purpose and service user guide should be updated. The manager needs to ensure that residents and their families are familiar with contracts and with their terms and conditions of residence. Some aspects of the plans require more detail, particularly in relation to personal and oral hygiene needs. The quality of recording in relation to tissue viability is variable and needs to be improved. The meal time process needs to be improved. OP7 OP8 OP15 Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Woodfield Grange Nursing Home DS0000001076.V306550.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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