Inspection on 21/07/09 for Woodhaven Residential Home

This inspection was carried out on 21st July 2009.

CQC found this care home to be providing an Adequate service.

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.

Other inspections for this house

Woodhaven Residential Home 04/08/08

Woodhaven Residential Home 26/04/07

Woodhaven Residential Home 23/05/06

Woodhaven Residential Home 14/12/05

Woodhaven Residential Home 01/06/05

Woodhaven Residential Home 01/02/05

Woodhaven Residential Home 07/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Woodhaven Residential Home Beacon Way Walsall Wood Walsall West Midlands WS9 9HZ Lead Inspector Amanda Hennessy Key Unannounced Inspection 08:30 21st July 2009 DS0000020843.V376127.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodhaven Residential Home Address Beacon Way Walsall Wood Walsall West Midlands WS9 9HZ 01543 377548 01543 453734 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) Woodhaven Homes Limited Miss Nicola Jane Smith Care Home 30 Category(ies) of Dementia (30) registration, with number of places Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE) 30 The maximum number of service users who can be accommodated is: 30 4th August 2008 Date of last inspection Brief Description of the Service: Woodhaven provides personal care and accommodation for up to thirty people over the age of 55 who have dementia. The home is situated in the Walsall Wood area of Walsall, in a quiet area, with easy access to bus routes and local amenities. The property underwent extensive renovation in 1999/2000 and consists of a two-storey building with thirty single bedrooms, all of which have an en suite toilet and wash hand basin. There are lounge and dining facilities on the ground floor and a small quiet lounge on the first floor. There is a small, lawned secure garden. There is a passenger lift to the first floor. The service user guide identifies that fees charged are between £343.83 to £405.00 per week for residency at Woodhaven, although the reader is advised to contact the service for up to date information on fees charged. Woodhaven Residential Home DS0000020843.V376127.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced Key Inspection was carried out by one inspector within one day from 8.30 a.m. – 4.30 pm; neither the home nor the provider knew that we would be visiting. There were 20 people in residence with 10 vacancies at the time of our visit. The National Minimum Standards for Older People were used as the reference for the inspection. Information for the report was gathered from a number of sources: a questionnaireAnnual Quality Assurance Assessment (AQAA) was completed by the Area manager and was sent to us before the inspection when we asked for it; We looked around most of the home including peoples rooms, bathrooms, toilets and communal rooms. Records about the safety of equipment and the building were also checked. Thirteen written surveys were returned directly to us from people living in the home and their relatives, these survey forms are known as have your say about Woodhaven, to enable people to tell us about their experiences of life at the home. We had discussions with the Manager, Area Manager, care staff and people who live in the home and their relatives, to gain their views of what it is like to live at the home. We looked at how the service has responded to concerns, how it protects people from abuse and how staff are recruited and trained. We also looked at the number of staff available to care for people who live in the home. Three people who live in the home were case tracked, this process involves establishing peoples experiences of living in the care home by meeting or observing them, discussing their care with staff, looking at their care records and focusing on outcomes of the care that they receive. Tracking peoples care helps us to understand the experience of people who use the service. As part of this process we also looked at peoples medicines, how they are ordered and records of their administration. Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 6 The inspection was conducted with Nicola Smith the Manager and Karen Cartwright the Area Manager joined us for the feedback at the end of the inspection. What the service does well: People told us that they were happy with the care provided at Woodhaven, they told us that: general care and cleanliness is very good.”, and “They look after us here”, “Staff are very caring, it’s always clean and there is no urine smell and the food is good”. “There is a friendly welcome for visitors regardless of the time of day. People have good information about the home and their needs assessed before they come to live at the home. This information gives them an informed choice that the home will be suitable for them. People receive good standards of care and support that meets their needs and choices. Health care need are met. A relative told us: “My relative is well looked after. She is clean and tidy; I am very satisfied with her care.” The home has robust staff recruitment and selection, which minimises the risk of unsuitable people working at the home and protects people who live there. What has improved since the last inspection? What they could do better: The storage and administration of medicines at the home is mostly undertaken safely and appropriately. Staff must however ensure that people do not “run out” of medicines as no person must be without their prescribed medication. Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 7 There is a need to inform us of all incidents that affect the health and well being of people living at the home, including violence and other potentially abusive practices between people living at the home. The home needs to have 50 of its care staff qualified to a minimum of National Vocational level 2 (NVQ2) which should be addressed when a new training provider can be found. Qualified care staff gives assurance that staff are highly trained and are more knowledgeable about people’s needs. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Woodhaven Residential Home DS0000020843.V376127.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 Woodhaven Residential Home DS0000020843.V376127.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs assessed and required information about the home is given to enable a decision to be made as to whether the home is suitable for them. EVIDENCE: The home has updated the service user guide and statement of purpose since our last visit and both documents provide detailed and clear information about the service. The service user guide and statement of purpose are also available in large print and pictorial format. People always have an option to visit the home before they make the decision to move in there. It was positive to see that people complete a survey on the Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 10 experience of their visit to the home to give the home information on their satisfaction or on ways that the home may improve. People have an assessment of their needs before a decision is made that the home may be suitable for them. The assessment of their needs is usually undertaken by the Manager. Assessment of people’s needs we saw contained detailed information about the person, their needs, choices and capabilities. It is also positive that a reassessment of peoples’ needs is undertaken in the first two weeks when they have lived in the home for a little while and staff have had more opportunity to get to know them and their capabilities. The service does not provide intermediate care. Woodhaven Residential Home DS0000020843.V376127.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home have their needs identified and met. The management of peoples medicines needs to be reviewed to ensure that people consistently have the prescribed medicine that they need. EVIDENCE: Care needs are identified following an assessment of people’s needs this information is then transferred into their plan of care. We were told that the service is about to review and further develop its care planning to make care plans more individual and more fully reflect their needs, choices and capabilities. Care plans we looked at generally provided comprehensive information about people’s needs and instructions for staff how these needs should be met, although we did identify some factual inaccuracies such as a Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 12 person’s incorrect religion and standard statements which were not appropriate for the person. The home has a key worker system. The persons key worker writes a weekly report and in addition to this all care plans are also reviewed monthly. Staff on each shift also make a record of the persons day and their general health. The service has good systems in place to monitor peoples health which includes risk assessments for falls, pressure sores and poor nutrition with actions in place to minimise any risks to the person. We were also able to see that when there is any changes to the persons health staff ensure that they are seen by their doctor. Relatives told us: “My wife is well looked after” and “General care is very good.” People have access to other health professionals depending on their needs such as opticians and chiropodists. We found that people have not been regularly seen by a dentist. Relatives told us; “I have told staff that X has had no false teeth for months, and I have asked that they are seen by a dentist.” The manager agreed that they have had a poor service from dentists and are now looking for a more reliable service to ensure that people receive the dental care that they need. The storage and administration of medicines at the home is undertaken by trained care staff and is undertaken mostly safely and appropriately with all required records in place. We did find that two people whose records we looked at had “run out” of their medicines. The Area Manager told us that the Doctor had been made aware of the situation but had refused to send out a prescription outside the normal monthly prescription request. We have advised the Area Manager that this is unacceptable and who they should contact for further advice to address this matter as no person must be without their medication. We also checked some of the balances of people’s medicines and found that another person had one more tablet left than there should be; this means that it is not certain that this person had had all the medicines that they were prescribed for. The homes induction programme includes a section on treating people with respect. We observed staff to knock before entering bedrooms and toilets and interacted in a friendly and open way using peoples preferred name. Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the opportunity to make choices about their life in the home and maintain relationships with friends and relatives. EVIDENCE: Peoples interests and choices are recorded within their care records. Staff try to ascertain the persons life history and background to enable them to get to know the person more. Staff ensure that information in relation to peoples choices such as the time that they go to bed and get up and food and drink that they like and dislike is identified. We were told that people can choose when they get up, go to bed and spend their day, which we also saw during our visit. Since the last inspection the home now has an Activity Organiser who works between the three homes in the group. The Activity Organiser was at the home during the morning of the inspection and it was evident that people thoroughly enjoyed the games, singalong and dancing that she facilitated. The Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 14 Activity Organiser told us that she has a plan for activities which include crafts, games, reminiscence sessions, singalongs as well as cooking. The home also told us: “We have an entertainer and music to movement session monthly and also celebrate major occasions like Easter, Christmas, Bonfire Night, Halloween, Birthdays and Anniversaries.” Visitors are able to visit the home at any reasonable time. Relatives told us: There is a friendly welcome for visitors regardless of the time of day”. The home also offers people living at the home the opportunity to take communion if they wish to. The home has a four-week rolling menu. People can have a hot breakfast every day if they choose to and in addition cereals and toast are also always available. The main meal of the day is at lunchtime. There is always a choice of meal available on the day of the inspection there was either cottage pie with potatoes and vegetables or hash browns, mushrooms and beans, although no one had chosen this option, there was apple crumble with cream or angel delight for sweet. There is always a hot snack option for tea such as cheese on toast with sandwiches also available. The food served was found to be tasty and was also enjoyed by people living at the home. Drinks are available throughout the day and there was a tray of cold drinks for people to help themselves to when they want. Meals are served both in the dining room and also in their own bedrooms if people prefer which we saw during the inspection. People living at the home told us: Oh yes the food is very nice. Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are appropriate procedures in place to listen to people who live in the home although there needs to be better reporting of aggression between people living at the home to give assurance that they al required action is undertaken to keep them safe. EVIDENCE: The complaints procedure is included in the service user guide and is also displayed in the home. There are copies of forms ‘Complaint’s, Comments and Compliments’ in the Reception area of the home and a suggestion box for people to use at any time should they wish to either raise a concern or pay the home and its staff a compliment. The home have told us that they have had six complaints since the last inspection. We found that there are appropriate records of all complaints that have been raised, including a record of the investigation and timescale of the homes response to the concerns. We have had two anonymous complaints about the home (included within the six that the home have identified). We visited the home as a result of the concerns but found that all but one of the concerns were not substantiated- a copy of the report of this visit which was Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 16 undertaken on 9th February 2009 can be requested separately. Relatives who returned our surveys told us: “We have no complaints at all only compliments about the home” and “concerns are dealt with appropriately, service users are respected Three surveys from relatives we received highlighted a problem with laundry with clothes going missing, clothes ruined by the tumble drier and the wrong items being returned. People told us: “Laundry is very poor”. There were no records of any concerns about the laundry but we were unable to confirm whether these people had discussed their concerns with the home manager to enable her to address these them. The home has had three adult protection referrals and when requested have provided a comprehensive investigation of any issues raised and have also attended meetings to discuss any safeguarding referrals. The home has also referred a member of staff to the protection of adults list as a result of the concerns highlighted. The home has ensured that all staff have had or are currently have a place to undertake “safeguarding training. At this inspection we found that staff we spoke to were clear of what may constitute abuse and what actions they should take to keep people safe and minimise any risk to them. We did however find that there has been ongoing aggressive behavior between two people at the home that frequently resulted in one person being hit by the other, staff told us: “I don’t think X likes Y but I don’t know why, she hits her most days.” These incidents and another incident of sexually inappropriate behavior had not been notified to ourselves or safeguarding as they should have been, the manager did tell us that she would do so immediately. The Manager has told us since the inspection they have a door alarm on one person’s door who has exhibited behavior that is challenging to alert staff when that person leaves their room. The home is also exploring alternative door locks to stop people wandering in and out of other people’s rooms. Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides adequate and safe accommodation for people who live there. EVIDENCE: The home is decorated and maintained to an acceptable standard. All bedrooms, communal areas and corridors have washable vinyl flooring. This has enables good continence and odour management throughout the home but means that some areas look cold or bare. There is some signage around the home to tell people the location of bathrooms and toilets, although not all bedrooms had names or numbers on to help people find their bedroom. Improved signage and more homely presentation in some areas would improve the facilities for residents who all have dementia care needs. Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 18 There is one main lounge area on the ground floor, which is pleasantly redecorated, comfortably furnished and well presented. There are also seating areas near the reception/lounge areas and a separate dining area, which people used during the day of our visit. There are two small communal areas on the first floor, one a quiet lounge/hairdressing room, the other a games/activity room. There is a small garden area to the rear of the home with garden furniture to enable people to sit out in the warmer weather. People told us: “I’d like to see them make more of the garden and keep it nice.” and “Maybe the garden are could be improved”. All bedrooms are single and have ensuite facilities. Whilst all bedrooms have vinyl flooring the AQAA does state that if people wish to have carpets they can discuss this with the owners and this is also included in the homes statement of purpose. All bedroom furniture is in very good condition and there are comfortable chairs also in people’s rooms. The security system is generally good, although the CCTV to protect the home and external and entry areas was broken at the time of our visit. The arrival and departure of all visitors and staff is secure, a member of staff required to release the door opening mechanisms. Standards of hygiene and infection control throughout the home were observed to be high and there were no mal-odours. Relatives told us: “It’s always very clean there is no urine smell,” and “The cleanliness is very good.” Woodhaven Residential Home DS0000020843.V376127.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has sufficient staff who understand and meet peoples needs. Recruitment and training processes are generally good but need slight improvement to give greater assurance that they protect people who live at the home. EVIDENCE: The home employs three care staff during the daytime one is a Deputy or Senior Carer – plus the Manager whose hours are supernumerary. At weekends three carers are on duty. There are three carers on duty at night. We were told that as the number of people living at the home or their dependency increases staffing numbers will be reviewed. (There are currently 20 people living at Woodhaven). When working the Activities Co-ordinator is additional to those hours and there are adequate numbers of support staff including domestic, catering, laundry maintenance and administration. We were told that absences are generally covered by existing staff. The home has five of its seventeen care staff with a training qualification (National Vocation qualification 2 or above). The AQAA told us that the Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 20 Manager is looking for a new training provider as the previous organisation has gone out of business, which should address this shortfall as we recommend that 50 of care staff have the above qualification. Mandatory training is ongoing. Although not all staff have attended all required training we saw that staff are booked to attend courses throughout the year which should address this, with the exception of new staff that will be booked onto courses in the near future. Staff recruitment and selection is undertaken appropriately and meets the required standard. All required checks such as criminal records checks and references are checked before staff start work at the home and ensure that any risk of unsuitable people working at the home is minimised and protecting people who live there. We did advise that the Manager ensures that she gains more information about prospective staff members employment history which includes dates of employment, which should be checked.We were also told that all new staff receive formal induction training that meets Skills for care standards. Staff we spoke to during the inspection told us that they were all satisfied with the support and supervision they received, although we were not able to evidence the frequency of staff supervision as records were not available. They felt that training they received was sufficient to ensure they had the necessary skills to meet peoples’ needs. Woodhaven Residential Home DS0000020843.V376127.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness, respect, has effective quality assurance systems developed a competent manager. EVIDENCE: The home’s manager has been successful in her application to be the registered manager for the home since our last inspection. Nicola Smith has worked at Woodhaven for four years initially as a deputy and also has more than seventeen years experience within care. The manager is currently Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 22 undertaking recommended management qualifications to manage a care service. The Manager has expressed a wish to continue to improve standards and has addressed all previous requirements and recommendations that we have made. Staff told us that the manager and providers are approachable and that they felt any concerns that they had are listened to. Staff told us: “I have respect for Nicky and she is very approachable.” “I love the residents I like the atmosphere here- it’s a nice place to work”. The Area Manager completed the homes AQAA which was returned to us when we asked for it. The AQAA gave us good information about the service and plans for improvement and development that are in place. A good Quality Assurance monitoring system is in place, which includes questionnaires to people living at the home, relatives and visitors including District Nurses and other health professionals– responses from these were seen. There are monthly questionnaires to relatives, sent to home addresses. Evaluation of recent surveys is being made and will be included with the Service Users Guide and Newsletter. The home has good arrangements in place for the safe keeping of peoples money. There is a record of all transactions with receipts available to confirm the transaction. A lockable drawer is also available in people’s rooms for secure storage if they wish it. Maintenance contracts were spot checked and were found to be up to date. Hot water temperature records showed that hot water is regularly checked and when there is any problem there is a record made of any actions that have been undertaken. As identified previously within this report it is important to notify us of all incidents that affect adversely affect the health, wellbeing or safety of people living at the home. We were told that there is a system is in place for staff to receive formal supervision at least 6 times per year, although this was not evidenced in staff records that were available and we were told that this is being undertaken by the Deputy Manager who was on leave. The homes record keeping is to a good standard. Woodhaven Residential Home DS0000020843.V376127.R01.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 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 People must receive the medicines that they are prescribed for. Staff must take required action to ensure that medicines are not out of stock. The service must report all incidents that affect people’s health and wellbeing which would include incidents that challenge between people living at the home. Timescale for action 21/08/09 2 OP18 13(4)/37 21/08/09 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 OP28 OP29 Good Practice Recommendations At least 50 of care staff undertake a care qualification ( a minimum of NVQ level 2) A complete employment history is available for prospective staff that includes dates of employment which whenever possible is checked. Woodhaven Residential Home DS0000020843.V376127.R01.S.doc Version 5.2 Page 25 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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