Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 24/08/06 for Woodford House Nursing Home

Also see our care home review for Woodford House Nursing Home for more information

This inspection was carried out on 24th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

Woodford House offers a genuine commitment to care with an open and personable approach, which reflects the homeliness of a confident relationship between carer and resident. The establishment of a professionally accountability towards effective assessment, detailed care planning and review of resident`s needs are meaningful and robust, in formulating a good standard of care. This personable attitude and approach to care is appreciated and welcome by residents and visitors alike. The management style demonstrated a professional approach in maintaining an environment conducive to the care of the elderly. There is a constant appraisal and review process of facilities and services to maintain that environment. Planning the daily life of all residents around the extension workhas resulted in minimal disruption, and no appreciable detriment to the quality of care or service.

What has improved since the last inspection?

The management has responded positively in dealing with the recommendations following the last inspection. Work has proceeded with the extension in providing upgraded facilities and four renovated bedrooms, all to a high standard.

CARE HOMES FOR OLDER PEOPLE Woodford House Nursing Home The Green Trysull Staffordshire WV5 7HW Lead Inspector Mr Keith Jones Key Unannounced Inspection 24 August 2006 09:00 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 Woodford House Nursing Home DS0000022384.V305442.R02.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. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 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 894934 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.V305442.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD(E) Over 60 years Date of last inspection 19th January 2006 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 28 service users including general nursing care. On the day of inspection there were 26 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 recent refurbishment had taken place, and also evidence that a continual programme of upgrading is established and is planned to continue following the completion of building to provide 40 beds. The CSCI will be appraised and involved in the planning and commissioning process. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted in a professional and cordial atmosphere with the care manager/provider and senior nursing staff. The last inspection report was discussed, and it was noted that all outstanding requirements and recommendations have been dealt with satisfactorily. On the day of inspection there were 24 service users in residence, of which 19 were categorised as requiring nursing care, 5 residential, of which 4 service users were being cared for with dementia. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of service users, relatives and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. Throughout the entire inspection a sense of familiar confidence pervaded into all aspects of daily activity expressed by those people met. A sample review of the administrative arrangements re-confirmed solid practice and effective management. The fees charged range from £375 up to £535 per week. A verbal report was offered at the end of the inspection to the care manager. There were 12 comment cards returned to CSCI, all complementary. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: Woodford House offers a genuine commitment to care with an open and personable approach, which reflects the homeliness of a confident relationship between carer and resident. The establishment of a professionally accountability towards effective assessment, detailed care planning and review of resident’s needs are meaningful and robust, in formulating a good standard of care. This personable attitude and approach to care is appreciated and welcome by residents and visitors alike. The management style demonstrated a professional approach in maintaining an environment conducive to the care of the elderly. There is a constant appraisal and review process of facilities and services to maintain that environment. Planning the daily life of all residents around the extension work Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 6 has resulted in minimal disruption, and no appreciable detriment to the quality of care or service. 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.V305442.R02.S.doc Version 5.2 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.V305442.R02.S.doc Version 5.2 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 The quality in this outcome area is good. This judgement is based on the examination of the homes policies, procedures, practices and discussions with management. Woodford House ensures that prospective residents have the necessary information to enable an informed choice to be made. Aims and objectives, terms and conditions are clearly presented in a way to facilitate easy understanding of services and standards of care. It is recognised that the Statement of Purpose represents the foundation on which the home operates upon, offering service users and their relatives the opportunity to make an informed choice about where to live. Following an assessment the senior/nurse assessor determines the suitability of the application in view of the facilities available, and of the capacity of the home, to manage the individual and any special needs. 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.V305442.R02.S.doc Version 5.2 Page 9 EVIDENCE: The Statement of Purpose and guidelines reflect an expression of philosophy, and have been well established in representing the foundation on which the home operates upon. It presents an excellent description of the home’s aims and objectives, philosophy of care and terms and conditions. All the requirements prescribed in Schedule 1 are addressed. The Care Manager is presently reviewing the key information policies of Statement of Purpose, Service User Guide and Resident’s contract to reflect the changing environment and circumstance on completion of the extension work. This review will be examined by CSCI at the commissioning stage, prior to opening the new wing. The care management adheres to an admission policy of personal supervision of the pre-admission assessment. Case tracking demonstrated the presentation of a highly personal approach to prospective residents and their relatives on pre-admission. Case tracking of four service users care records showed that 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 nurse 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 and discussion 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. There was an appreciation of the difficulties surrounding the extension work, yet there were no comments made throughout the inspection programme, including pre-inspection comment cards from residents, relatives and professionals. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 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 and 10 The quality in this outcome area is good. This judgement is based on the examination of four care plans, discussions with service users, staff, managers, general observations and the homes medication system. The care assessment and planning system is an organised, yet personalised process offering meaningful and valid documentation of care administered. A broad vision of needs is addressed through the care planning process, attempting to meet personal and health needs. It is recognised that this reflects an individual profile of needs, discussed fully with family. The provision of a secure and safe medicines administration is generally managed efficiently, although there is a constant need to maintain standards. A secure storage and recording system is advised to manage controlled drugs. Staff were seen to demonstrate a personal empathy with residents through a respectful, yet friendly discourse. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 11 EVIDENCE: Four service users were case tracked, with a full examination of care records, health records including professional and general practitioners visits, risk assessments, dependency charts, records of reviews and action plans. The pre-admission assessment represented the foundation for a well-considered and detailed care planning process. A profile of the service user’s social, physical and emotional status offered an individual plan of care, based upon daily living reviewed monthly. A detailed assessment was examined and found to collect a full profile of physical and psychological needs, as well as social, cultural and environmental circumstances. Residents with dementia have a Roper, Logan and Tierney activity of daily living assessment process. The Home plans to provide care for 6 mental illness nursing care needs service users. The process of assessment, care planning and review are well aligned to meet this criteria of care. Evidence of health care professional visits showed an attentive awareness to service user’s needs. Daily reports were acknowledged as a valuable process that have been standardised for all service users. There was evidence of consultations from medical specialists and other professional support services. 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 medication systems were found to be generally well organised, secure and efficient. Controlled drugs were secured and accurately recorded. However there were instances where some non-administered drugs had not been recorded, especially aperients and lotions. It was agreed that these items are subject to the same scrutiny and attention to administrative procedure as oral drugs and medicines. Plans to extend the provision of medicines are advanced with the purchase of an extra drug trolley, and greater storage space in a purpose-built clinical room, based in the new extension. Examination of the accident records showed consistency in the completion of the record, with clear descriptions of injuries and interventions made. The spiritual orientation of each service user is recognised within care records. The prevailing personable atmosphere in the home is extended to encompass the needs of relatives and friends during difficult times. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 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 15 The quality in this outcome area is good. This judgement is based on discussions with service users, staff and examination of records in relation to social activities undertaken and general observations during to course of the inspection. 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. Relatives are usually the preferred option for control of money. Some service users preferred to keep small amounts themselves, and a locked facility was available in each bedroom. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 13 The appointment of a full time activity coordinator has had a meaningful influence on the standards of care and social needs of residents. There was sufficient evidence in observing and talking to people, that there was an extensive appreciation of promoting a socialisation approach. Remedial and diversionary activities were popular and appreciated. Residents are encouraged to mix, and extend their social life to external events, i.e. visits to the pub, holidays etc. One confused resident who understood English but responded in Italian, had attentive appraisal in producing suitable language cards, and motivated through his love of music. Records showed the positive reaction, confirmed when meeting the gentleman. Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. Newly renovated bedrooms were found to be of a high quality in fittings and furnishing. A varied menu is available for service users on a four-week cycle and represent a wholesome, appealing and varied balanced diet. Lunch was served during inspection and meals seen to be wholesome and nutritious with service users enthusiastically agreeing on the quality of preparation and serving. Three meals are offered to the service users daily, along with snacks and hot and colds drinks throughout. Special dietary needs are catered for and monitored as was evidenced through case tracking. Some service users choose to have their meals in their bedrooms. The dining areas were very pleasant, offering conducive ambience for a social meal. 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 and seen to be up to date and accurate. Some repair work on a water heater was hindering operations, and was duly removed to the workshop. The cook was reminded to have available access to coats/protective clothing. COSHH signs and notices were in evidence with cleaning chemicals secure, appropriate and under control. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 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 The quality in this outcome area is good. This judgment is based on the examination of the homes complaint procedure and the recruitment procedure of staff to ensure the protection of service users. The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. 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. 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 policy was seen and records examined. There were few minor complaints assessed, all dealt with at the source. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. Case tracking confirmed the effectiveness of a care manager and staff sensitive to service users needs and readiness to test the robustness of their information Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 15 and report structures. As part of the process of encouraging self-determination a policy exists to be able to offer advocacy services should they be required. Family involvement has been the usual means of representation in the past. One complaint has been received since the last inspection and was not upheld. Residents’ 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. This process was evidenced on examination, and case tracking as previously reported upon. 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. It was confirmed that abuse is established as a regular feature on the annual training programme for all staff. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 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 quality in this outcome area is good. This judgement was based on discussions with service users, staff and a tour of the premises. 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. Some areas that have had work done, including a full doubleglazing and roof rafter renewal. Four renovated bedrooms are now complete. 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. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 17 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 conducting a commissioning inspection in late September 2006 on completion of 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 scrappy décor that was awaiting a full redecoration following the extension work. There are 6 variable height beds available for use. On inspection all 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. Some wardrobes in refurbished rooms had not been secured. 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 extension will provide two extra lounge areas, one with a conservatory design. 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. 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. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 18 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, prior to commissioning. 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. All bedrooms will be secured on completion of the extension work. The Care Manager was advised on appropriate secure systems to accommodate mental health demands. 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.V305442.R02.S.doc Version 5.2 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 quality in this outcome area is good. This judgement was based on the examination of staff files, working rotas and discussions with staff. The staffing levels in relation to the number of service users in residence and their dependency level was suitable to meet the needs of service users. Staffing stability has been maintained with consistent levels to ensure equilibrium between numbers, skills and qualifications, with a strong presence of long serving experienced staff. Care bank are occasionally used, agency rarely, with agreed overtime and flexible rostering to accommodate shortfalls. The management have established a comprehensive procedure for interview, selection and appointment of staff. The thoroughness of staff selection has a significant effect upon the provision of cares to ensure protection of service users. All staff receive training in care issues within the home from registered nurses and external trainers. EVIDENCE: The duty rotas for weeks commencing 01/08/06 through to the 31/08/06 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. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 20 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 full participation of unit managers, with the Care Manager supernumerary. Agency coverage has been rarely used since the last inspection; overtime and flexible rostering meet shortfalls. An average daily coverage was recognised for each unit: 07.00 – 14.00 - 2 RGN 4 carers 14.00 – 21.00 - 1 RGN 4 carers 21.00 – 07.00 - 1 RGN 2 carers The catering, domestic and laundry hours were determined and found to be appropriate for the size of the home and the needs of the residents. The home has a full time activity organiser. The care manager emphasised the home’s commitment to training and to achieving targets for NVQ level 2. There are 15 staff with NVQ level II and level III, representing 90 achievement. There are 5 certificated first-aiders in the home’s staffing establishment. Five 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. The process would benefit from a formal interview record. Ongoing personal and training records were kept secure in accordance of the Data Protection Act 1998. Policy clearly states an equal opportunity position. Three on-duty members of staff were interviewed, each expressing their working conditions openly and with confidence. Each individual was complementary as to the level of training and supervision they receive. Evidence showed attention to an improved supervised training involving a shared aspect of responsibility between staff and trainer. Training plans drawn up were examined and found to offer an excellent commitment to the educational, supervision and appraisal process. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 21 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 quality in this outcome area is good. This judgement was based on discussions with the Registered Manager, the examination of the home policies and procedures with regards to the effective management of the home, general observations during the process of the inspection and discussions with service users and staff. EVIDENCE: 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. She has recently been elected to chair the employers group of the representative body, Staffordshire Social Care Workforce Partnership (SSCWP), and has completed NVQ Level 4 RMA award course of study. It was pleasing to see this standard continuing to be well met. The care Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 22 manager has a developed formal approach to monitoring quality across a wide range of activities. This includes care risk assessment, care plan review process that is recorded at least once a month, a staff training programme and an environmental risk assessment prevention programme. This includes the setting of objectives, effective budgeting of plans and target dates to aim for, with forward planning in setting objectives on short-term and long-term planning, as evidenced in the arrangements of extension to Woodford House. Evidence was secured to acknowledge achievements, ongoing and planned objectives. Involved within this process are the views of service users and relatives, confirmed at case tracking and informal discussion. Social Workers’ review meetings are often a vehicle for assessing quality. Staff meetings are held monthly. Each service users has a personal file containing contractual, financial and personal information. Care plans were drawn up, implemented and reviewed with service users and relatives whenever possible. Case tracking and informal discussion provided evidence that participation is encouraged by the service user themselves, or by their relatives. 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. These included procedures on first aid, racial harassment and ‘Whistle blowing’. Service records for gas supplies, emergency call system water, and fire inspectors report are to be upgraded for the commissioning meeting. Planned maintenance and risk assessment ensures that essential services linked to utilities and safety, are monitored and serviced on a regular basis. Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training. 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 reported recently. 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.V305442.R02.S.doc Version 5.2 Page 23 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 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 4 18 4 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 4 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.V305442.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 OP26 3 OP2 4 OP30 5 Refer to Standard OP29 OP9.3 Good Practice Recommendations To establish the practice of providing a written record of staff interviews. That all instances of non-administration of medicines be recorded to determine reason for non-administration. Access to the kitchen area to have readily accessible overclothing available. To ensure that equipment requiring maintenance does not impede routine operations, i.e. in the kitchen area. That wardrobes are secured to adjacent walls. That staff training records be kept within the individual’s personal file. Woodford House Nursing Home DS0000022384.V305442.R02.S.doc Version 5.2 Page 25 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.V305442.R02.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!