Inspection on 23/01/08 for Woodhall Park

This inspection was carried out on 23rd January 2008.

CSCI found this care home to be providing an Poor service.

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

Woodhall Park 19/10/06

Woodhall Park 14/09/05

Woodhall Park 22/06/05

Woodhall Park 24/06/04

Woodhall Park 08/07/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Woodhall Park Risley Hall Derby Road Risley Derby DE72 3SS Lead Inspector Helen Macukiewicz Unannounced Inspection 23rd January 2008 09:45 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 Woodhall Park DS0000002126.V356246.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. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodhall Park Address Risley Hall Derby Road Risley Derby DE72 3SS 0115 9490444 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) woodhall_park@btconnect.com Mrs Linda Isobel Ann Crosbie Miss Diane Joy Quincey Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one named service user under the age 65 for the duration of their care. 19th October 2006 Date of last inspection Brief Description of the Service: The Home provides nursing for up to 41 older people. It is situated in an appropriately adapted building, in a pleasant park setting in Risley. It is situated near to public transport. The administrator said that the fees are currently between £425.00 and £630.00 per week. Extra items that will need to be purchased on top of these fees include toiletries, newspapers, hairdressing and chiropody. Copies of the Inspection reports for the home are available in the foyer You can get a copy of the latest Inspection report on our website at www.csci.org.uk Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This Inspection was unannounced and lasted 7 hours during one day. 5 preinspection questionnaires were received from people living in the home, 2 from current staff members and 1 from a relative. Findings from these questionnaires are included in this report. The self-assessment of the service had been completed and returned and information from this was used in the planning of this inspection. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were also referred to in the planning of this visit. During this Inspection discussion with people who use the service and their relatives took place. Time was spent in discussion with the nurse in charge, the administrator and staff. Four residents care files were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and staff records. A brief tour of the home took place including some bedrooms. Pharmacy Inspectors undertook two interim unannounced Inspections on 18th December 2006 and 19th March 2007. The purpose of these visits was to follow up on medication errors that had been reported to us. Reference to these Inspections and any requirements will be made in this report where necessary. An ‘expert by experience’ assisted with the inspection process. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The ‘expert by experience’ was present for three and a half hours and spoke with six residents, three visitors and two members of staff. She ate lunch with the residents. Her findings are incorporated into the report. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Management of the service needs to be improved, so that staff are provided with leadership and guidance in the delivery of care. Systems must be put in place to monitor areas of practice that are not satisfactory, such as giving out Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 7 and recording of medication, some aspects of care planning and recruitment of staff. Care records need to demonstrate that people’s care has been reviewed and continues to meet their needs. Risk assessments and agreement by the individual and/or relative must be completed when equipment such as wander mats and tilt back chairs are used. This must be in line with the Mental Capacity Act. People must receive their medication as prescribed, which means that staff must improve their practice in both the giving of medication to people and recording this information. This has been an ongoing concern since December 2006. Staff must have up to date and accurate knowledge about how to protect people from abuse and harm. Staffing levels need to be reviewed to ensure that sufficient staff are on duty at all times to meet peoples needs. The recruitment of staff must improve so that people living at Woodhall Park are protected from harm. The required pre-employment checks had not been completed for all staff employed at Woodhall Park. An immediate requirement was issued at the time of the inspection, requiring the provider to take action within 24 hours of this visit. Staff must have induction and foundation training, so that they have the skills to meet the needs of the people in their care. 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. The summary of this inspection report can be made available in other formats on request. Woodhall Park DS0000002126.V356246.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 Woodhall Park DS0000002126.V356246.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3, standard 6 does not apply, the home does not offer intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are procedures in place to ensure people are appropriately admitted to the home and their needs can be met. However, out of date information provided by the service means that people are not always able to assess whether the service is suitable for them. EVIDENCE: The management of the service were aware of the need to update some of the information about the home (service users guide and statement of purpose) although this has not been done yet. This means that people may not have accurate information about the home. One of these documents was on display in the foyer, and contained inaccurate information (complaints procedure). Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 10 Admission procedures for the home were looked at and showed that the service was able to meet peoples needs before they moved in. One resident said that when they came, their son sorted out the admission. They couldn’t remember being given a brochure and said they did not meet the staff before being admitted but the matron came to collect them from hospital. Another resident said they were assessed prior to admission and had been given a brochure and Statement of Purpose. They were asked about their general health as well as social interests. Documentation belonging to another resident also supported that pre-admission assessment took place. Residents and relatives satisfaction surveys supported that good pre-admission procedures were in place. Not everyone could remember being given a contract but they felt they had enough information to make a decision about the home. One resident said, ‘I’ve got everything I want- this is the best hotel in the world’. ‘It is a nice place, I am well cared for’. The Inspection report was seen in the foyer. Woodhall Park DS0000002126.V356246.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7-10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Sufficient information is provided in care records to support staff to meet peoples assessed personal care needs. However, medication practice is unsafe which means that people’s health is put at risk. EVIDENCE: Four residents care files were seen. All of the basic information about people had been recorded and plans of care were in place. Accidents were recorded in the care plan and accident book. There was evidence of updates and reviews to the care plan. Three residents had no photograph on the care plan, which would help identification by new or agency staff. The staff had made an attempt to demonstrate residents/relatives involvement in forming the plan of care by asking them to sign to agree to them. One resident said that they had signed their care plan and felt fully informed of Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 12 their care needs. However, there were some gaps in signing updates to care plans on residents who had stayed at the home for a longer time. Care files contained risk assessments for continence, moving and handling, skin condition, nutrition and falls. There was evidence of review and that this had been used to inform the care plan. One resident said ‘you are well cared for, you couldn’t be cared for any better’, ‘I am ever so contented here’. Another resident said they had seen the dentist and optician and GP, they were due to see the chiropodist the next week. Care records detailed GP visits and evidence that the physiotherapist had seen residents. One visitor said their friend had improved since they had been living in the home and appeared well looked after. Comments received via satisfaction surveys from residents showed that they have medical support when needed. One resident wrote ‘everything is satisfactory’ and ‘meets all my personal needs’. One relative’s survey recorded ‘everything is provided for my brother and he is very happy’. All residents and visitors who were asked reported that they were satisfied with the care that the residents were receiving. One resident said ‘you are well cared for – you couldn’t be cared for any better’ and ‘I’ve got everything I want, this is the best hotel in the world’. Residents confirmed that staff treat them with dignity and respect and that their privacy is upheld. A visiting health professional said that in their opinion the home is well run. They said there is always one or two nurses available and that they want to keep the patient in the home if they can manage. They always followed instructions and were good at managing records. Another visiting professional said the staff appeared to look after people well although they had observed people waiting a long time to be taken to the toilet. Residents’ satisfaction surveys stated that care is provided when needed, although one commented that they have to wait sometimes before being assisted to the toilet. The minutes of a relatives meeting that took place in October 2007 recorded that relatives at the time had raised issues about people waiting a long time to be taken to the toilet, suggesting that this is an ongoing problem that is yet to be addressed by the service. Although residents said that their dignity was upheld, this issue does impact on the dignity of some. Previous random inspections carried out by our pharmacist have found that medication management systems were unsafe and service users were not receiving medication as prescribed. Consequently this area of care was looked at closely during this visit to see if improvements had been made. However, the evidence outlined below indicates that the required improvements have not been made. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 13 There was evidence to suggest that medication prescribed for residents was being used for other residents. This was demonstrated by original prescription labels being removed or written over by staff on a number of prescribed barrier creams in bedrooms. One hair treatment product was seen in a bathroom for general use, with the prescription label completely removed. This may mean that people receive medication that is not suitable for them, or may react with other medication they are on, as well as their doctor being unaware. Observations of the actual administration of medicines showed that safe practices were not being followed, as the nurse was signing for medicines that had yet to be given. Storage of medication did not support that only in date medication was being used, as several containers of eye drops/ointment were not dated with an expiry date. This means there is a risk of out of date medication being used. There was also the risk of people receiving medication no longer required, as it was still in the cupboard. There was the potential for people to receive medication not approved by their doctor, as medications purchased as homely remedies had not been approved but were being used as homely remedies by staff. Homely medications were mixed up with prescribed products making them hard to distinguish within the medicine store cupboard. A check of the medication record sheets showed that a prescription for a controlled drug had been changed by a handwritten entry. This had not been countersigned to ensure its accuracy, which is good practice. There were many signatures missing from the administration records over the 3 week period that was checked, so it was unclear as to whether residents were getting their medication. Variable doses of medication were not always accurately recorded as to the number of tablets given each time. A second signature, as good practice, did not always accompany hand written changes to medication. In one case, a medication had been stopped without any date or signature. One nurse reported that they had not had any refresher training on how to administer medications safely in the last 2 years. For those people who were self-medicating there were safe systems in place. A check of controlled drugs showed these were being appropriately stored and checked. Checks of the medication fridge temperatures were recorded. Woodhall Park DS0000002126.V356246.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to choose how they spend their day but their lifestyle is enriched by planned social care activities. EVIDENCE: Staffing rotas showed that an activities co-ordinator was employed for 5 days/week. The co-ordinator was experienced in this field and her programme was wide-ranging and interesting. Included were: quizzes, exercises, singsong, outside entertainers, discussions, beauty treatment, shopping expeditions and parties. One resident said they have things going off in the afternoon. They had a daily newspaper, which they paid for. They had a flexible daily routine, TV and radio in the bedroom. A visiting professional said she thought there was always something going off activity wise. In their satisfaction surveys, residents recorded that most find there are activities on offer that they can join in. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 15 One resident was happy with the arrangements for using the phone and said they have regular visitors and can see them in private if needed. One or two residents described a flexible daily routine, which was supported by staff. One resident said ‘staff treat me nice, treat me with respect, they always knock on the bedroom door’. Access to the community consisted of an occasional outing. Residents may go out of the building with relatives or friends. Residents raised no concerns about their privacy and dignity and felt that their choice and freedom was respected. Most, however, did not have a key to their bedroom door. A visiting professional said that the home employed a physiotherapist once a week and Holistic therapist twice a week. Whilst there was clear evidence of activities taking place, there was little evidence within care files that the activities programme was based on individually assessed needs. A life story sheet was included in the care files but was only completed in one out of the four care files seen. There was no social care plan in any of the care files. A record of the religious preferences of the person was not recorded in three out of the four files, and in one their nationality was not recorded. One resident said the food was ‘marvellous’. They could have tea in the bedroom. Resident’s comments in their completed questionnaires confirmed that they enjoyed the meals provided. Fresh fruit was being offered on a regular basis and observations showed that staff were assisting people to eat this. There was a choice of main meal which was both nutritious and well presented. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have access to an effective complaints procedure and are kept safe although documentation does not support that their rights are fully protected. EVIDENCE: A copy of the complaints procedure was displayed in the foyer. In their satisfaction surveys, all residents and relatives recorded that they knew how to make a complaint and were happy with existing procedures. One resident said ‘I have no complaints’. If they were unhappy they would see a nurse. During this Inspection, two residents knew how to complain, although two did not. Only 1 complaint was recorded as having been received and records showed this had been dealt with appropriately. Although it was reported that safeguarding procedures in place, they could not be located at the time of this visit. However, a member of trained staff was able to describe the actions she would take, and these were appropriate. Staff were provided with training on safeguarding procedures, although not all staff had attended this training. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 17 There was a risk assessment and consent in place for use of equipment that carries a risk of restraint in the care files, such as bed rails. However, use of other equipment like wander mats and tilt back chairs were not recorded in the same way. The new care documentation did not allow for proper consent in line with the mental capacity act. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout enables people to live in a safe, wellmaintained and comfortable environment. EVIDENCE: There had been clear investment in the homes’ environment. All areas were well presented and there was evidence of carpet replacement and redecoration. A sensory garden was in the process of being built and appeared to be of a good standard. One resident said the place was very clean; staff thoroughly cleaned their bedroom once a week. Maintenance requests had been acted upon straight away. A visiting professional said there was continuous investment in the homes environment. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 19 One visitor said the home was always clean and smells fresh. Residents and relatives who completed questionnaires said that the home was clean. One commented that there were ‘very good cleaners’. Some residents had more choice regarding privacy than others. Most of the bedrooms could not be locked and did not have a lockable space inside. Some residents who were more able to live independently had a door lock for their bedroom and some personal lockable space inside. However, although it was mentioned in some minutes of a meeting with relatives/residents that door locks had been offered there was insufficient evidence to support that all residents, including those less able had been given the opportunity to make an informed decision in this area. A bathroom near first floor lounge had a broken privacy lock. There was sufficient equipment to deal with soiled laundry. Two residents said that the ‘The laundry is marvellous’. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27-30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shortfalls in staff training and recruitment means people are put at risk. EVIDENCE: The nurse in charge said that most of the time there was only one nurse on duty when the manager was absent from the home, as the manager provides the second nurse cover. Although other qualified nurses were employed, they were working as care staff to cover deficits in numbers. Staffing rotas showed that agency staff were not being used to provide second nurse cover when the manager was absent. The rota and comments from staff indicated that the planned number of staff ( 2 nurses and 6 care staff in the morning / 1 nurse and 5 care staff in the afternoon) was not always achieved. Staffing rotas showed that some members of staff were working a high number of hours in a week. One member of care staff was recorded as working 62 hours in 1 week without a day off, and another, 51 hours. There was evidence to support that the staffing situation was affecting outcomes for people living at Woodhall Park. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 21 One resident said the home had been a bit short of staff lately but that staff had coped well. They thought some more staff had been recruited. They also said that when they rang the call bell, staff were quick to come ‘you only have to ring for a nurse and they come’, ‘Staff treat me nice’ and ‘the staff are marvellous’. Another resident also said that the home was sometimes short of staff but it has not affected them. They said staff spoke to them as an equal. A further resident said that staff were quick to come if they called the bell. However, one person did say that they thought staff shortages meant those people who needed more assistance had to wait a bit longer for things like assistance to the toilet. One resident complained that staff were sometimes impatient when help was being requested. A visitor commented that their relative had to wait too long to be taken to the toilet and two people said that occasionally there were insufficient staff on duty. The staffs attitudes and performance were deemed to be satisfactory by other residents. One visitor said that the staff were always pleasant and there was a good atmosphere at the home. However, in the completed satisfaction surveys, both residents and relatives recorded that the staffing arrangements for the home were satisfactory. Staff surveys indicated that staff themselves felt they got enough information to enable them to do their job and that they received training. Staff recruitment was inadequate and placed residents at risk of being cared for by unsuitable people. The recruitment files for five newly employed staff were seen. These showed that not all required pre-employment checks were being obtained. Police records were not being checked before people started working at the home. Health declarations as to the person’s fitness to do the job were not being asked for and not all references were acquired. Immediate action was requested from the administrator to ensure residents were kept safe at the home in the form of an immediate requirement, to be acted upon within 24 hours. Training records for six staff were seen. These showed that they were receiving some of the mandatory training that is required in areas such as first aid, food hygiene and moving and handling. Two files showed the member of staff had not had safeguarding adults training. One member of staff said they had never had safeguarding training in the years since they had started working at the home. However, other areas of mandatory training such as fire safety had been received. There was an induction/foundation training record booklet in the files. There was evidence in these to show that some staff had received a basic ‘tick box’ induction. However, there was little evidence in most files to support that staff Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 22 completed a full induction or received the foundation training they required, including some who had no experience in a care setting previously. The number of staff having achieved National Vocational Qualifications to level II in care subjects was also below the required 50 of total care staff. Woodhall Park DS0000002126.V356246.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36,37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home does not ensure people are safe. EVIDENCE: Neither the manager nor deputy manager were available on the day of this visit. The manager has been unavailable for work at regular intervals during the past 12 months, which has impacted on the leadership and guidance that staff have received. We were notified following this visit, that the manager had left her employment. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 24 Residents were happy and contented living in the home, feedback from them was very positive. However, there was evidence to suggest that the home was not being managed as efficiently as required. Changes/developments to key policies and information about the home had not been acted upon. This means that people were not getting the correct information about things like how to make a complaint. Staff were not being supervised appropriately, staff training was not being monitored so staff were not progressing through foundation stage training after they started employment, or receiving safeguarding training. Unsafe medication practices continue, despite requirements being made during previous visits to the service. The audit tool used to monitor medications was only identifying gaps in signing medication sheets and not other poor areas of practice. Continued gaps in signing for medications means that this type of monitoring is not being effective in keeping people safe. There were gaps found in the monitoring of individualised social care, which means that despite a wide range of activities, there was little evidence to support this was based on the actual needs of the residents. Management had not been effective in ensuring that residents’ rights with regard to consent and freedom of movement were fully upheld. The accident records for period September 2007 – January 2008 were seen. Incidents were well recorded. However, they showed that there were a high number of incidents occurring. These showed lots of falls resulting in skin tears, many of which were happening whilst staff were assisting residents to move. The number of accidents of a similar type did not seem to have reduced in the period looked at. It was reported that accident records were audited although these records were not available, and the evidence does not support that these audits have been effective in reducing the number of similar incidents. It was reported that the owner of the home did undertake regulation 26 monitoring visits each month, and produces a report on the overall performance of the home. However, these records were not made available to the management of the home, and there was little evidence that they had been effective in improving the overall management of the home. It was reported that satisfaction surveys had been sent out to relatives, staff and residents in the past, but there was no documentation to show how the results of these had been used to improve quality within the home. At the time of the visit, there was no annual quality assurance plan for the home. Minimal money is kept on behalf of residents, the systems for managing money were seen and relatives and residents said they were happy with the way the home handles money on their behalf. A review of the policies kept by the home, undertaken by staff in a self assessment form completed prior to the Inspection, showed that there were Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 25 several key policies that are recommended such as quality assurance, induction, planning and review and pressure relief, that were not in place. Qualified staff said that they had not had formal supervision. Looking at supervision records, it was clear that these were not taking place at regular intervals for all levels of staff. One member of staff had been working at the home for 5 months; they had no experience of working in a care home before. They had received 2 supervisions since they had started, both of which recorded that the supervision had consisted only of fire safety instruction. Some of the maintenance works for the prevention of Legionella were not clear. A Legionella risk assessment, which would clearly detail the regular maintenance works that were required, was not available at the time of this visit. There was no chlorination of the water tanks or weekly water checks recorded. The last bacterial analysis was done in 2003. It was reported that a visual check of the digital display of circulating water temperatures was carried but not recorded. A file containing general risk assessments of the environment was seen. There was a sign in the foyer stating that the home was rated 4 stars at the last Environmental Health Officers visit. There were records to show that other equipment is regularly serviced and maintained. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 X X X X 2 X 3 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 2 2 Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 28 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement There must be safe administration of medicines to ensure the safety of residents. Prescription labels must not be altered or defaced. Prescribed medications must not be re-dispensed for use by other residents. Staff must ensure medications have been taken before signing medication charts. Out of date medications must be removed from the home. Medications must be labelled correctly to ensure they have not gone out of date. Homely remedies must be stored and used correctly, consistent with an approved homely remedy policy. An accurate record of medicines given must be maintained e.g. numbers. Hand written changes to medication charts must be accompanied by a date and signature. Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 29 Timescale for action 01/03/08 2. OP12 16(2)n 3. OP18 13(7) 4. OP24 12(4)(a) Original timescales of 12/02/07 and 19/03/07 not met. There must be a plan of care for 01/04/08 each resident stating how the home is to meet their social needs, which supports that consultation has occurred and that activity programmes meet individual needs and preferences. Any equipment that has a degree 01/03/08 of restraint must only be used following a full assessment of need, regularly reviewed and documented with consent in the service users plan of care. To ensure service users are safeguarded and that regard to the Mental Capacity Act has been given. There must be documented 01/04/08 evidence to support that all residents, including those less able have been given the opportunity to make an informed decision about whether or not they want door locks and personal lockable space within their bedroom. The broken bathroom lock must be repaired. This is to ensure that residents have their privacy and dignity respected and that they are given informed choices about how they live. There must be adequate 01/04/08 numbers of suitably qualified, competent and experienced staff provided, to ensure service users needs are met with dignity and to ensure their rights are upheld. Staff must not be employed to 24/01/08 work in the home until all the DS0000002126.V356246.R01.S.doc Version 5.2 Page 30 5. OP27 OP28 18(1)(a) 6. OP29 19(1)(a) and (b) Woodhall Park and Schedule 2. required pre-employment checks stated in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001 have been obtained. POVA first and Criminal Records Bureau checks must be applied for, for the two members of staff most recently employed and written evidence to support this provided. 7. OP29 19(1)(a) and (b) and Schedule 2. 18(1)(a) 8. OP30 Immediate requirement left. A system must be put in place to ensure that recruitment checks on staff are undertaken prior to commencement of employment, and this must be evidenced in staff files. This will ensure that residents are safeguarded. All staff must be provided with training appropriate to their role and to include safeguarding adults and medications. Original timescales of 01/02/07 and 19/03/07 not met. The registered provider and registered manager must manage the care home with sufficient care, competence and skill to ensure the well being and safety of residents. There must be effective arrangements for the management of the home during the absence of the registered manager. There must be effective oversight and monitoring of the home by the Registered Provider. To ensure the home is run in the best interests of service users and to ensure they are safeguarded. DS0000002126.V356246.R01.S.doc 01/04/08 01/05/08 9. OP31 10(1)12 (1)(a) 01/03/08 10. OP33 10(1) 12(1)(a) 01/03/08 Woodhall Park Version 5.2 Page 31 11. OP36 18(2) 12. OP38 The registered Provider must ensure that all staff are appropriately supervised, including the manager. To ensure the service is run in the best interests of service users, and to ensure they are safeguarded. 13(4)(b)(c There must be effective ) monitoring of accidents that occur in the home. This must be recorded to demonstrate what action is being taken to ensure the safety of residents. There must be a risk assessment and maintenance records for the water system to demonstrate that the home is undertaking appropriate Legionella prevention works. 01/04/08 01/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations There should be up to date information within the statement of purpose and service users guide so people have accurate information on which to base their choice of home. A photograph should be kept on the care plan, which would help identification by new or agency staff. A second signature should be obtained where changes are made to the medication administration record, as good practice. The manager should address the issue of people waiting prolonged periods to be assisted to the toilet, in order to ensure their dignity is upheld. The manager should ensure that all residents know how to make a complaint so their rights are upheld. Staff should not be working more hours than the working DS0000002126.V356246.R01.S.doc Version 5.2 Page 32 2. 3. 4. 5. 6. OP7 OP9 OP10 OP16 OP27 Woodhall Park time directive requires unless there is documented agreement. Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 33 Woodhall Park DS0000002126.V356246.R01.S.doc Version 5.2 Page 34 - 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!