Inspection on 19/01/06 for Woodford House Nursing Home

This inspection was carried out on 19th January 2006.

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

Woodford House Nursing Home 11/06/08

Woodford House Nursing Home 24/08/06

Woodford House Nursing Home 06/07/05

Woodford House Nursing Home 24/01/05

Woodford House Nursing Home 06/07/04

Woodford House Nursing Home 14/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Woodford House Nursing Home The Green Trysull Staffordshire WV5 7HW Lead Inspector Keith Jones Unannounced Inspection 09:00 19 January 2006 th 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 Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 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. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodford House Nursing Home Address The Green Trysull Staffordshire WV5 7HW 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) 01902 324264 01902 324264 Heart of England Properties Ltd T/A Woodford House Nursing Home Mrs Juliet McDonagh Care Home 28 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (14), of places Physical disability over 65 years of age (28) Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD(E) Over 60 years Date of last inspection 6th July 2005 Brief Description of the Service: The home holds a centre point in the very attractive Trysull village, conveniently located close to local amenities, overlooking the village green.The home provides care of the elderly for up to 31 service users including general nursing care. On the day of inspection there were 21 service users in residence. Over the years Woodford House has been transformed from the village hotel to provide a very comfortable care home with the necessary facilities in place to offer a high standard of care. Situated on two levels with a passenger lift, the home boasts an attractive split-level roof garden with outdoor seating areas. There are pleasant gardens, well maintained throughout the year for the pleasure and convenience of service users, although an area has been set aside for the extension presently under construction. There is adequate car parking available. It was noted that a continual programme of upgrading is established and is planned to continue following the completion of extension building work to provide 40 beds. The CSCI will be appraised and involved in the planning and commissioning process. It was noted that 8 beds have been closed down for the duration of the extension work. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was conducted with the provider/care manager and senior nursing staff. The last inspection report was discussed, and it was noted that there were no outstanding requirements or recommendations. The tour of the home was carried out in a relaxed, courteous and professional manner, everyone concerned expressed confidence in the atmosphere, liking it to a family feeling. All the service users approached were highly complimentary of the care, service and attention they received from a willing, attentive care team. There were 21 service users on the day of inspection, categorised as requiring nursing care. Three service users were case tracked confirmed the establishment of a well run, very comfortable and ‘homely’ establishment. Relatives who were present were equally complementary of the family approach to care, the freedom they enjoyed and the involvement that the manager and her staff encouraged. Everyone appeared comfortable and at ease with their surroundings. A sample review of the administration confirmed solid practice and effective management. Discussions with service users and staff over the building work indicated that the influence is minimal. A full report was offered at the end of the inspection with open discussion involving the registered care manager and latterly the provider. What the service does well: Woodford House offers a high standard of care and service, is extremely well organised, with a committed care management team. Emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Assessment procedures and care planning is of an excellent standard, offering detailed information on each resident’s progress in the meeting of objectives. The housekeeping and support services all contribute to the team approach, and are recognised by the management for their efforts. Maintenance of good staffing levels, staff training and supervision are well established in safeguarding the interests of residents. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 6 Overall the attitude in meeting caring and organisational demands is highly commendable, with forward thinking, planning and application contributing to an excellent service. The present extensive building and maintenance work has been controlled effectively to minimise the interference to daily life. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 It is recognised that the Statement of Purpose represents the foundation on which the home operates upon, offering residents and their relatives the opportunity to make an informed choice about where to live. Following an assessment the senior care assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the individual and any special needs. The care manager is to review the primary documents following the completion of extension work. The Statement of Purpose, User Guidelines and contracts are actively being reconsidered by the provider. The Home has demonstrated their commitment to promote a partnership of care, to meet the objectives of providing a home to meet individual needs. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 9 EVIDENCE: The Statement of Purpose and service user’s guide represent a good description of the home’s aims and objectives, philosophy of care and terms and conditions, offering service users and their relatives the opportunity to make an informed choice about where to live. All the requirements prescribed in Schedule 1 are addressed. The document is kept under a consistent review to reflect changing circumstances. It is clearly stated in the Statement of Purpose that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of service users. The Statement of Purpose also clearly indicates the terms and conditions, which are discussed with service users and relatives prior to admission. This documentation is presently under review. A pre-admission assessment, always carried out by a senior member of staff appreciated any special needs of the individual including cultural, social or personal needs, which are fully discussed and documented. This assessment initiates the process of care, each individual having a plan of care based on a daily living process. The Home demonstrated through case tracking, that the assessor explained this information in respect of each individual to ensure a clear understanding is established. The registered person also makes a judgement as to the suitability of each prospective service user using the same criteria. An appraisal is made, and discussed, to ensure the home can satisfactorily meet those needs. Case tracking and discussion with service users confirmed that this standard continues to be well met. Following an assessment the senior carer assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the individual and any special needs. Likewise the applicants are informed of those facilities and are encouraged to seek clarification concerning the general and specific services available for the prospective service user. Case tracking confirmed that a valuable exchange between service users and assessor took place and resources made available. These resources were seen to be an appraisal of staffing skills, equipment and general environment. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 The service users’ assessment provides the base from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has a GP provision that visits the home frequently. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The Inspector was impressed with the confidence and closeness within the Home of staff, residents and visitors, and the mutual respect that prevailed. There exists a straightforward, yet effective medicines administration system, accurately monitored and actioned. EVIDENCE: Three case records were examined and found to offer a clear, well balanced, up to date and accurate appraisal of requirements. Reviews were done on a minimum of once a month, usually more often, as needs dictate. Case tracking of those three residents confirmed the depth of care planning supported by a solid foundation of organisation and quality services. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 11 The system would benefit with a clear record of date of assessment, and signature of the accountable person. The home has good links with specialist services – continence advisor and tissue viability. A profile of the service user’s social, physical and psychological status offered an individual plan of care, based upon a model of daily living, to be implemented and frequently reviewed. Each service user’s health, personal and social care needs were seen to be assessed in an individual plan of care that is reviewed monthly, including service users and relatives views, to reflect their changing needs. That review is more frequent, dependant upon the individual’s needs and clinical condition. A tour of the premises evidenced that there was a range of pressure relieving equipment, and examination of service user plans found that all are assessed in relation to pressure sore risk, falls risk and nutritional risk. The administration of medicines adheres to procedures to maximise protection to service users. The storage was secure with satisfactory added security for controlled drugs. A controlled drug register was examined and found to be in order. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. The Statement of Purpose clearly and openly states that the wishes concerning arrangements after death would be discussed and respectfully carried out, ascertained as soon as possible after admission. The spiritual needs of service users were recorded and observed by the staff with due respect. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 12 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 14 Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. Service users’ life-styles and interests are recorded in their care plan, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. Personal choice and relative selfdetermination are respected in policy and action. Those who wish to bring in personal possessions are encouraged to do so. Service users were offered a varied and nutritious choice of meals from a 4week rotating menu. Special diets were accommodated with the cook making every effort to engage with service users to discuss personal preferences. Staff were seen to offer discreet assistance to those who required it. EVIDENCE: Discussions with service users and staff clearly identified a relaxed atmosphere in which the service user’s needs were respected. A routine exists to establish a framework for managing the home, not as a yardstick for service users to comply with. Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are familiar events to the day they could relate to. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 13 Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. The good standards of catering at Woodford House offered an excellent service, to which service users spoken to were complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and excellent choice. An excellent lunch was served during inspection, with choices available, served in a well-furnished and clean dining rooms. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. The kitchen was inspected with the cook and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. A cleaning schedule was in place which needs to be recorded on a daily basis to evidence the high quality observed. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 14 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): 16,17 and 18 It is the clear policy that Woodford House enables any staff member, service user, service user representative or visitor to the home to lodge any complaint or concern they may have about any aspect of their service. The care manager showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures EVIDENCE: The complaints procedure was presented within the Statement of Purpose and contract, displayed in reception, and identifies the registration details. The complaints file was examined and found to be satisfactory. There was one outstanding issue at the time of inspection. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. Advocacy service is available to those who require it as indicated in the service user guidelines. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. The care manager showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 15 Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. Steps have been taken to secure booklets from the General Social Care Council’s Code of Conduct for all staff to help reinforce the induction and training programmes. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 16 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 The location of Woodford House is conducive for a care home, situated in a small village setting with good access to road links, and a short drive to Wolverhampton. The standard of the environment within this home is subject to an extensive programme of building including an imminent and ongoing refurbishment programme, facilitating a curtailing of admissions for the period of renewal. Four bedrooms have been closed for the duration of the work. Some areas that have had work done, including a full double-glazing and roof rafter renewal. The management has effectively controlled the progress of the work. This issue was discussed with residents and visitors who all seemed to be enlivened with the increase of activity and general interest generated by the work. The arrangements to accommodate these activities ensure a continuity to provide comfortable homely accommodation despite the size of the building Each of the bedrooms provided a satisfactory level of furnishing and facilities to which each resident has been encouraged to add their personal belongings, furniture and décor as the wished. It was most encouraging to observe a clean and pleasant, odour-free atmosphere, much to the credit of staff. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 17 It is acknowledged that a major refurbishment of all rooms, involving fittings, furniture and equipment has been planned, with a commitment offered by the managers. A new conservatory will also be available by the end of the year. There is evidence of an awareness of health and safety issues being high on training and supervision priorities. Individual rooms are presented as highly personalised and inviting individual domains. EVIDENCE: External access is satisfactory for visitors, although building work is restrictive. Service users take advantage of attractive gardens and grounds; pathways are risk assessed, were safe and recently attended to. Building work is evident but represent no overt risk to service users. CSCI will be involved at various stages during the work. Letters have gone out to families and friends keeping all parties informed and up to date. On admission a trained nurse assesses each individual service users needs for equipment and necessary adaptations. Internal access was facilitated with ample fittings of hand and grab rails, in adequate, well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the home. Bedrooms were well maintained to meet service user’s personal preferences. It was evident that there were examples of minor maintenance to décor that was awaiting a full redecoration following the extension work. There are 3 variable height beds available for use, with 2 more on order. On inspection most bedrooms were personalised, with some displaying service user’s own furniture, and most with personal belongings. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration. There is generally a good standard of furnishing complimented with a variety of personal belongings. Some of the Home’s furniture needs varying levels of attention to maintain the existing high standards. All communal areas are of a high standard, offering social as well as private reflection, as the mood takes. A large lounge space allows activities to be presented in a very pleasant, animated area of the home with furniture and fittings of good quality. The dining area was adequate, having been recently re-floored, and corridors wide enough for wheelchair access, well lit and with sufficient handrails. Service users have the provision of sufficient and suitable lavatories and washing facilities within the home. The standard and presentation of all the toilets and bathrooms were of a high quality, clean, uncluttered and odourfree. Two bathrooms have recently been upgraded with impressive results. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 18 Adequate attention has been given to ensure maximum privacy within riskassessed boundaries. 17 rooms have en suite facilities of a good standard. There are adequate sluice facilities, each having suitable arrangements to assist in control of infection. The areas that store chemicals displayed appropriate COSHH posters and information charts. It was acknowledged that the care manager has reviewed environmental risk assessments, to establish an impressive foundation for maintenance management. A recent Fire officer’s report was received in regard to essential remedial work on a fire escape at the rear during the extension work. A further, full fire inspection will take place on completion. An effective nurse call system is installed; care staff reacted speedily to tests. The care manager expressed a willingness to meet any reasonable demand for special needs. There is an adequate lighting, and bedside lamps are available where risk assessed. Radiators are protected; smoke detectors fitted and adequate electrical sockets available. A locked facility and lockable bedroom doors were made available on request, following suitable risk assessment. The evidence seen on inspection of service user’s rooms, and on discussion with the individual service users and family, assured that this standard was well met. Several service users spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. The standard of cleanliness continues to be seen to be excellent throughout; there were no offensive odours in any of the rooms inspected. Sluices, bathrooms and toilets were cleaned on a routine basis presenting a hygienic environment. Kitchen presentation showed good standards of cleanliness and evidence of sound food hygiene practices. The laundry was well organised and equipped to a good standard, with new equipment recently installed. COSHH regulations were clearly displayed and relevant to solutions in use. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 19 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 The daily care staffing rota showed adequate balance between skills, qualifications and numbers to provide a foundation for a good standard of care. The overall general skill mix and numbers of staff working in the home meet the needs of the service users. Examination of two staff files has shown a consistency of procedural application, resulting in an effective procedure to ensure the protection of service users. The home employs a full complement of support staff, including maintenance, part-time administrator, laundry staff and adequate domestic and catering staffing levels. The care manager informed the inspector of routine staff induction programmes, well established and well designed on which formed the base upon which in-service supervision and training are planned and achieved. Formal staff clinical supervision has been established, which continues to need to be extended to encompass general working standards and be part of the cascaded package involving all the staff. EVIDENCE: The inspection was conducted with the care manager/provider, and it was confirmed that there were 21 service users in residence on the day of inspection, 14 being categorised as needing nursing care. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 20 The duty rotas for weeks commencing 16/01/06 through to the 6/02/06 were available, inspected and staffing levels were seen to be satisfactory. The overall general skill mix and numbers of staff working in the home meet the needs of the service users. The daily care staffing rota showed adequate balance between skills, qualifications and numbers to provide a foundation for a good standard of care. Shifts are supported with hours from care manager (2 shifts a week). Agency coverage has been rarely used since the last inspection; overtime and flexible rostering meet shortfalls. An average daily coverage was recognised: 07.00 – 14.00 - 2 RGN 4 carers 14.00 – 21.00 - 1 RGN 4 carers 21.00 – 07.00 - 1 RGN 2 carers At the time of inspection there was one RGN vacancy. There were 11 RGNs working 228 hours a week and 15 care staff working 635 hours a week. In addition there are four carers on various stages of adaptation programmes, being resident in the village. It is envisaged that the programme will continue with support from Derbyshire University and four in-house supervising RGNs. Activities and socialisation is presently organised by the care staff, but it is expected to appoint a part-time Activity Co-ordinator working 30 hours per week in the near future following the extension completion. There was 3 domestic staff working the early shift on a routine basis, i.e. 180 hours, and a two staff 49-hour laundry services. Each service will be reviewed on work completion. There are 5 catering staff working within 102 hours, a 40-hour maintenance man and a 30-hour administrative support. It was noted that the care manager worked 25 of her working week as a clinical team leader, 75 as the home manager. The provider plays an active contributory role in effective management and direction. The care manager emphasised the home’s commitment to training and to achieving targets for NVQ level 2. There are 16 staff with NVQ level II and level III, 2 staff working towards level 2, and 2 member of staff who do not wish to be put on training. There are 10 certificated first-aiders in the home’s staffing establishment. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 21 Two staff files were sampled and found to be well organised and up to date, following a review of procedures. It was evidenced that CRB checks have been made and contracts of employment are up to date. Ongoing personal and training records were kept secure in accordance of the Data Protection Act 1998. Policy clearly states an equal opportunity position. Woodford House has developed an extensive training plan, evidenced by a 2005 schedule, a significant and impressive commitment to staff training and education, conducted on a professional footing. There is a need to generate a report that clearly identifies the training effort, especially in fire prevention and movement and handling. The care manager was advised to institute an annual programme to include abuse, and its many forms. Records show a very broad spectrum of clinical and allied subjects covered, ensuring that staff fulfil the aims of the home and meet the changing needs of service users. Consideration is being given to seek student nurse allocations. The care manager and deputy lead from the front as facilitators and mentors, and are actively seeking new horizons for their personal portfolio of training. All staff receive training in care issues within the home from registered nurses and trainers. Evidence showed a diligent attention to clinical supervised training, involving a shared aspect of responsibility between staff and trainer, with the involvement of mentor trained staff. However there is a continued need to extend this process by involving general working arrangements to offer a more substantial commitment to the supervision and appraisal process. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 22 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): 31,32,33,34,35,36,37 and 38 The care manager Juliet McDonagh offers a considerable resource of experience and skills, which are reflected in the high standing in which Woodford House is held by residents, their relatives and the community alike. The style of management was seen as by direct observation, and by discussion with service users, relatives and staff, and that a very open and positive attitude prevails, enhancing the home’s ‘family feel’ and homeliness. There was strong evidence of openness and honesty in speaking with service users, relatives and staff in which day to day events and episodes were freely discussed. On-site inspections offers evidence of a management firmly in control, well organised and prepared to facilitate meaningful, delegated responsibilities to an efficient care management team. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 23 EVIDENCE: The care manager has demonstrated competence in running Woodford House in establishing a solid Statement of Purpose and policy portfolio that has been implemented, to achieve a high standard of set aims and objectives. A qualified general nurse with a BSc (Hon), a professional portfolio of practical and managerial experience, including a newly acquired NVQ level IV manager’s award is well suited to her present position. Staff meetings are held fortnightly in which staff are encouraged to participate fully in the management and direction within the home. The inspector observed at first hand the confident interrelationship that exist not only between management and staff, but also between staff and residents. The care manager has reinforced the presence of quality assurance with a monthly audit of standards, and regular review of risk assessments. There was strong evidence of openness and honesty in speaking with service users, relatives and staff in which day to day events and episodes are freely discussed. Evidence was secured to confirm a quality monitoring system has been introduced, based upon audit of standards, care plans and feed back from service users and relatives. Standards are discussed at staff meetings, daily reports, direct observation and involvement and one to one staff meetings. The procedures manual was randomly examined and found to offer a very comprehensive reference, although these policies are in need of review to reflect changing circumstances and contemporary issues. A report from a fire prevention inspection had been completed to accommodate arrangements during the extension work. Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training sessions organised by a member of staff recognised as a fire safety officer. Discussion with the care manager indicated that supervision sessions and individual training programmes are areas that with continuing improvements, will enhance the desired impact on quality of service. The Statement of Purpose is clearly recognised as the foundation for providing a high standard of care through effective quality assurance and adherence to working policies, procedures and practices. Each service users has a personal file containing contractual, financial and personal information. Several files inspected evidenced a satisfactory standard of maintenance and security of these files. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 24 A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment for elderly service users. Accidents were seen to be addressed, risk assessed, actioned and recorded in an effective way, with access to Riddor if needed. No serious accidents have been recently reported. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 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 3 3 4 4 4 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 4 18 4 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 3 3 3 3 3 Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP36 OP19 Good Practice Recommendations Supervision of carers is to be formally documented six times a year. That there is a review of fire training . Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Woodford House Nursing Home DS0000022384.V271472.R01.S.doc Version 5.0 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. 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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