Inspection on 26/04/07 for Woodhaven Residential Home

This inspection was carried out on 26th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodhaven Residential Home 21/07/09

Woodhaven Residential Home 04/08/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodhaven Residential Home Beacon Way Walsall Wood Walsall West Midlands WS9 9HZ Lead Inspector Bhag Jassal Key Unannounced Inspection 26th April 2007 09:35 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 Woodhaven Residential Home DS0000020843.V335785.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. Woodhaven Residential Home DS0000020843.V335785.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 vacant post Care Home 30 Category(ies) of Dementia (30) registration, with number of places Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 55 years and above Date of last inspection 20th September 2006 Brief Description of the Service: Woodhaven provides personal care and accommodation for 30 people over the age of 55 who have dementia. The home is situated in the Walsall Wood area of Walsall, in a quiet street, 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 30 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 garden, but this is not large enough to accommodate all the service users at one time. There is a passenger lift to the first floor. The home currently charges service users between £324.08 - £365.00 per week for residency at Woodhaven. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is on a key inspection, part of which included an unannounced visit undertaken on 26th April 2007. This unannounced visit started at 9.35 a.m. and lasted 9 hours and 10 minutes. The home had 25 places occupied and 5 beds remain vacant. The judgements made within this report are based upon information supplied by the home, from interviews with staff and service users and from relatives. During the course of inspection the assessment information and care plans were inspected for 6 service users. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with Health and Safety legislation. A tour of premises was also undertaken and observation of care practice and interaction between staff and service users was also completed. Six service users files were looked at to enable the Inspector to monitor progress in meeting previous requirements. Discussions took place with 6 members of staff and several service users were spoken to throughout the day. Acting Care Manager – Ms Nikki Smith was present from 11.00 am onwards to the end of the inspection. Ms Della Burnham – Deputy Manager assisted the Inspector with the inspection process until the Acting Care Manager arrived at the care home. On this occasion all the Key Standards of the National Minimum Standards were inspected. Regulation 37 Notifications and Regulation 26 reports received from the care home were also considered and discussed with the Acting Care Manager. What the service does well: Woodhaven care home is registered for 30 older people with Dementia care needs. The home makes every effort to provide individuals with a good care to meet the assessed needs following a care plan. The home has a good key worker system and staff supervision system in place. The home communicates well with the families/friends and representatives of the service users. The visitors’ book indicated a lot of activity. The service Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 6 users spoken with said that they are happy and content with living in a homely and caring place. Service users were in the lounges engaging in their daily routines and activities and they further commented that they were comfortable and satisfied with the care provided. The visiting relatives also confirmed this to the Inspector on the day of inspection. The atmosphere within the home was observed to be relaxed, comfortable and friendly. Friendly rapport was also observed between service users and staff. Meals are varied, balanced and well – presented to meet each individual’s needs, preferences, likes, and requirements. Most of the service users spoken to who could express themselves in a meaningful way stated their satisfaction with the care they received and they commented “the food is very good here and tasty”, “I am very happy in this place” and “the staff are very good caring and kind”. “The Manager is very good and she sort things out for us”. The home has a training programme, which all members of staff will be involved in. Several members of staff have completed their NVQ Level 2 training, and a number of them have also completed their mandatory training in safe working practices i.e. health and safety, fire safety, first aid, moving and handling. All senior staff responsible for administration and safe handling of medication have completed their training in this area. Thus this training will ensure that they are improving their knowledge and skills to meet the changing needs of service users. The home provides adequate standard of accommodation and facilities. What has improved since the last inspection? The home has made good improvements in their record keeping and care planning. Care Plans seen for service users were informative and gave some indication of how care is to be delivered for each of them. But some improvements need to care planning processes. Staffing levels at the home have improved and there is now more staff on duty to help with meeting the service users’ needs. Medication practices have improved and more staff have received training in safe handling of medicines. A number of staff have completed their training in Dementia care and that will enable them to expand their knowledge and skills and enhance the care they give to the service users. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 7 It was noticeable that there have been some improvements made to the environment of the home. A rolling programme of decoration has been implemented, and communal areas have been redecorated and new items of furniture have been provided. 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. The summary of this inspection report can be made available in other formats on request. Woodhaven Residential Home DS0000020843.V335785.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.V335785.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): 3 and 6. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Woodhaven Residential care home provides clear information to prospective service users and their families to enable them to make decisions about whether or not they wish to live at the home. All prospective service users receive a full/comprehensive needs assessment prior to admission to ensure that their needs will be met. EVIDENCE: Admissions are not made to the home until a full assessment has been undertaken. At present the Acting Care Manager visits all service users at their home or hospital prior to admission. There was evidence in the six service users files/care plans that were seen which contained pre-admission assessments of service users needs, both from assessments by the Acting Care Manager and other relevant professionals. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 10 Observations and discussions with the service users, the Acting Care Manager and staff on duty indicated that the home continues to meet the individual needs of all service users accommodated at the home in a satisfactory and sensitive manner. The requirement made in the previous inspection report in respect of Dementia care training, it was noted that several members of staff have received this training and others are being nominated to undertake this mode of training, commencing in June 2007. Formal staff supervision is now taking place and Dementia care is discussed as an ongoing matter. The requirement made in the previous inspection report regarding all contacts must be signed and dated by the service users to demonstrate their understanding of the terms and conditions of residency. The Acting Care Manager stated that this has been carried out either by the service users or their relatives/advocates on their behalf. The home does not offer intermediate care. Woodhaven Residential Home DS0000020843.V335785.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): 7, 8, 9 and 10. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan of care but these do not detail how their needs will be met. Health care needs are addressed promptly. Medication is generally managed safely and people who use the service are protected by the home’s policy and procedures. People who use the service are treated with respect and dignity, and their rights to privacy are understood and upheld. EVIDENCE: All service users undergo an assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 12 Six service users’ care plans and files were examined in detail and it was noted that the short-term and long-term goals, aims and objectives were not clearly identified and appropriate interventions required to put them into action to meet the individual service users’ needs also were not identified. It was noted that the care plans are now being reviewed on a monthly basis. The Acting Care Manager stated that service users (and where appropriate their relatives) are now involved in the review of their care plans. If it is thought to be impractical to involve service users then this is documented on their care plans. However, there was evidence to show that there were some gaps in that some of the care plans have not been reviewed on a monthly basis. The daily care (day and night) care recording formats were also examined and it was noted that the quality and detail of recording needs improvement. The Acting Care Manager stated that she will ensure that the staff are aware of the importance of including all information regarding service users’ well being, and all the entries made by staff are always to be cross-referenced to care plans. The Acting Care Manager also stated that the revised and updated formats of care plans and daily care recordings will be implemented immediately; and the staff will be closely supervised and supported to make further improvements in daily care recordings as a matter of priority. The home maintains records of all health checks carried out by doctors, opticians, dentists, district nurses and chiropodists. Each service user is assessed by the senior staff to determine whether or not they are at risk of developing pressure sores. District Nurses visit the home regularly and support staff with the provision of pressure relieving equipment as necessary. The Acting Care Manager confirmed that at present there is no service user in the home with pressure sores. The home also completes a dietary needs assessment that details each service users’ abilities at meal times and lists their likes and dislikes and the type of help needed. All service users are weighed monthly and this helps staff to monitor the service users‘ well - being and physical conditions. People who have specific conditions such as diabetes and epilepsy generally had management plans in place to ensure that staff were aware of their individual needs. All of the people resident at Woodhaven have some form of dementia and occasionally they demonstrate some behaviour that challenges staff. This means that staff may find it difficult to meet the needs of service users without specific guidance and training. This was discussed with the Acting Care Manager during the inspection and she is to take appropriate action to provide staff with guidance on managing such likely behaviours. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 13 Service users are also assessed for their need to have bed rails to ensure their safety whilst in bed. It was noted that bed rails are checked on a regularly and staff are made aware of their safe use. Medication practices within the home have improved greatly since the last inspection. The medication room was found to be clean and tidy, medication was stored appropriately. Evidence gathered from the staff records and from discussions with the Acting Care Manager showed that staff are now taking part in accredited training in safe handling of medicines, and this will ensure that they are aware of the processes involved in administering medicines and enable them to do it safely. A requirement made in the previous inspection reports with regard to the service users must be assessed in line with the home’s policy for self-administration of medicines. Now this information is being obtained at the pre-admission needs assessment stage. The needs assessment format has been amended to reflect this. Thus the previous requirement has been deleted. Medication rounds were observed during the inspection. Staff were seen to administer and record when medicines had been given. The Acting Care Manager stated that all senior carers, who are responsible for the safe handling and administration of medicines have completed their training in safe handling of medication. Records seen included medication received, administered and leaving the home. It was noted that the mobile medication trolley was securely stored after use in the medication room. It was observed on the day of inspection that no personal care interventions were undertaken in communal areas. In addition, consultations with health and social care professionals are carried out within the service users’ bedrooms. Visitors are able to meet service users in their bedrooms and lounges. It was also observed that service users were being treated with respect and staff are working both professionally and sensitively in meeting individual needs. The staff work hard to try and maintain the dignity of service users, which can be difficult at times due to the type of illness and conditions they have. Relatives have commented that they are pleased with the care their relatives received, but sometimes there are difficult situations the staff having to deal with. The Inspector spoke at some length with several service users, who were able to have meaningful conversation; they stated they were happy with the care provided and staff were very helpful and caring. Three service users stated that the carers are always there to help, and we are very pleased with them. However, during the discussions with service users they also said that on occasions the carers are pushed for time when they have to cover sickness and other duties. Woodhaven Residential Home DS0000020843.V335785.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): 12, 13, 14 and 15. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide a structured programme of social and leisure activities and outings, which are designed to meet the service users’ needs, preferences and capabilities. Visitors are welcomed and there are links with the local community. Service users are positively helped to exercise and control over their lives as far as practicable and safe to do so. The dietary needs of service users are well catered for with a balanced diet and varied selection of foods, of ample quantities to meet the tastes and individual requirements of service users. EVIDENCE: It was noted that the home does not provide a structured programme of social and leisure activities inside and outside the home in accordance with service users’ with dementia care needs, their preferences and capabilities. There is no proper system of maintaining records of activities in the home. The home does not have a staff member designated to organise social and leisure activities, who would identify the interests that the service users wish to Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 15 pursue. The care plans do not clearly identify the social and leisure needs of service users. It was also noted that there is very little in the way of entertainment and activities within the home and no outings and trips have been arranged during the recent months. However, the Acting Care Manager stated that a carer is to be identified who will act as an activities co-ordinator and will have the responsibility to plan and implement in the home in liaison with other carers a programme of social and leisure activities for all service users. The external entertainers would also be invited to deliver entertainment in the home for service users with dementia care needs and their abilities. The Acting Care Manager stated that she will ensure that the social and leisure needs are clearly identified in their care plans, and any activities enjoyed by the service users will be incorporated into their individual care plans. However, activities seen during the day of inspection included singing, listening to music. Several service users were engaged in conversation with each other whilst others sat listening to music and seen tapping their feet to music. Several of the service users spoken to stated that they are in regular contact with their family members and friends, and spoke about their visitors’ interest and involvement in their care matters. The visitors’ book kept in the home showed a considerable activity. Family and friends are encouraged to visit and the home has an open visiting policy. There was a steady flow of visitors during the day of inspection. Some of the visitors commented that “its good to see the residents taking part in doing some activities, and its good for them”. Relatives of two service users stated that they visit the home at various times of the day as they wish. Three relatives who also spoke to the Inspector said they are given warm and friendly welcome by the staff whenever they visit. Service users also keep some contacts with the local community – for example, church services, shops and park. The Acting Care Manager stated that the service users are positively assisted and helped to exercise choice and control over their lives as far as practicable and safe to do so. A close liaison is maintained with the relatives and representatives where the service users are not able to make decisions. Service users and their relatives are informed about the availability of the local Advocacy Service based at the local Age Concern office. Several service users told the Inspector “the food was very nice and tasty”. The consensus of service users was the range, quality and choice of food provided was very good and the home caters for those service users who have individual preferences and medical needs. The Acting Care Manager stated Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 16 that the current four weekly menus were changed very recently and in consultation with the service users. The kitchen is well equipped and has a well stocked food supply. The catering staff are well trained in food safety and hygiene matters. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and professionally. Service users are protected from abuse by the home’s policies and procedures. Formal training is required for all staff to ensure that service users are protected from abuse. EVIDENCE: The home has a good complaints procedure, which is referred to for information in the Service Users’’ Guide. There is a satisfactory system of recording concerns and complaints. Since the last inspection one complaint has been made and the Acting Care Manager has satisfactorily addressed this. Two service users’ relatives when asked were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff in charge or the manager. The home has not had to report any vulnerable adult protection issues. The home has good policies and procedures in place regarding restraint, dealing with aggressive behaviour and prevention of abuse, which includes whistle blowing policy. The Acting Care Manager stated that adult protection issues are discussed during induction training and supervision meetings. However, formal training in adult protection issues has not yet been provided to all members of staff. It was noted that all members of staff have been nominated Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 18 to undergo this mode of training with a local training agency (Organisational Development – Social Care). As yet confirmation of places and dates are not known. Thus the requirement made in the previous inspection report in respect of adult protection training has been reviewed and noted the progress being made by the home. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 24 and 26. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained but needs some improvements to décor, furniture and safety matters. The home is clean and hygienic. EVIDENCE: A tour of the premises highlighted a number of issues that must be addressed to improve the internal environment. Paintwork is looking tired and in need of refreshing. The Acting Care Manager stated that there is a planned programme for maintenance with timescales for specifics jobs, including redecoration of bedrooms and communal areas, and renewal of old furniture items. There is a small lawned garden. There is not sufficient outdoor and accessible space for service users. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 20 Since the last inspection the corridors on the first floor have been redecorated. However, relatives have commented about the décor within the home stating that it would benefit from renewal. The hot water supply in several bedrooms was not working and needs to be rectified promptly. It was noted that the home’s handyperson/maintenance worker had a look at the specific rooms with hot water supply issues and he tried to make it safe for use until the next day when all the remedial work to be carried out. The garden furniture was still in need of cleaning and could not be used by the service users and their relatives. On the day of inspection the garden still needed to be tidied up to make it more inviting for service users and their families to use. These both issues were discussed with the Acting Care Manager and the Area Manager - Karen Cartwright and were rectified on the day of inspection. The carpets in several bedrooms are in need of replacement with suitable floor covering. The home was found to be generally clean, tidy and free from any unpleasant odour. The home has good policies and procedures regarding infection control. However, the staff group still needs to receive training in infection control. This issue is outstanding from the last inspection report. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The number of staff on duty on day shifts has improved and there are sufficient numbers of staff to meet service users’ needs, but two vacant posts of care staff needs filling. Recruitment procedures have improved but require fine - tuning to fully protect service users. The home continues to support staff to complete training, but not all staff are yet adequately trained to do their jobs. EVIDENCE: Information provided by the home and the available staff rotas on the day of inspection indicated that the home is now adequately staffed at all times. The Acting Care Manager’s hours are supernumerary and there is one senior and four carers on duty in the morning and one senior carer and three carers on duty in the afternoon and there are three waking night staff. The home also employs kitchen staff, domestic and a maintenance worker to ensure the home runs smoothly. Staff were spoken to and all stated that despite the changes in staff recently they felt they were for the better and they were beginning to work as a team. The relatives spoken with also made observations about the staff team “they all are working hard to provide good care and attention to our relatives here”. Service users were full of praise for care staff stating they “are very caring and Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 22 kind and do anything for us”, “I’ve not long been here but they helped me to settle in”. However, two vacant posts of a day carer (36 hours per week) and a night carer (24 hours per week) must be filled as a matter of priority. It was noted from the staff training records and discussions with staff and the Acting Care Manager that six members of staff have completed their NVQ Level 2 training and the remaining staff are being enrolled to undergo this training. The Acting Care Manager stated that a number of staff have undertaken their mandatory training in safe working practice topics. It was also noted from the staff training records that not all members of staff have received training in safe working practice topics and they are being put forward to undertake this training. Staff are also being nominated to receive training in adult protection issues and Dementia care. All new staff are receiving their induction training in accordance with the Skills for Care standards/requirements, and staff confirmed that they are fully supported by the home for any training needs that they have. Since the last inspection the home has operated an acceptable recruitment procedure. On inspecting six staff files, it was noted that now all staff are POVA and CRB checked. Two written references are also obtained. The job application forms are fully completed and contain full employment history. The Acting Care Manager stated that any gaps in employment are also explored/discussed with the job applicants during the interviews. The requirement made on this issue in the previous reports now has been deleted. There is evidence on files that staff receive statement of the terms and conditions of employment. There is now staff training and development programme in place, which is being implemented shortly. The Inspector was informed that there has been staff “resistance” to undergo training courses, which is being appropriately addressed by the management of the home. Woodhaven Residential Home DS0000020843.V335785.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): 31, 33, 35 and 38. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The Care Manager is not registered with the Commission for Social Care Inspection. Service users can be assured that the home is generally run in their interests. Service users financial interests will be safeguarded. The home generally promotes the health, safety and welfare of its service users and staff, but need some further improvements. EVIDENCE: The home is currently without a registered Manager. However, the Registered Providers have appointed an Acting Care Manger Ms Nikki Smith over a year ago. Ms Smith is currently undertaking her RMA training course. She appears to be managing the home well. Ms Smith stated that her application to register with the CSCI has been completed and is ready for submission to the Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 24 CSCI shortly. There are clear lines of responsibility and accountability within the home and the Acting Care Manager is well supported by the Registered Providers. The home has a formal staff supervision system in place and now this is being implemented. Observations made and discussions with service users, their relatives and staff have indicated that the Acting Care Manager is very approachable and she operates an open door policy. The service users, who could express themselves stated that they are happy to approach the Manager and staff with any problems they might have and were confident that they would respond to them appropriately. It was noted that the home has a Quality Assurance monitoring system in place, which includes questionnaires to service users, visitors and relatives to obtain feedback on quality of service provided by the home. The Acting Care Manager confirmed that she has recently sent out the questionnaires to all service users, their families/friends and other visitors to the home. She said that she will complete the report on the outcome of the feedback by the end of July 2007.and report will be made available in the home and a copy to the CSCI. All the financial records and administrative procedures relating to six service users’ monies within the home that were inspected were found to be well ordered and maintained. The home has good health and safety policy and procedures, and staff are aware of their responsibilities regarding these issues and a number of staff have received training in these issues. Matters pertaining to fire safety and environmental health needs to be maintained to the required standards and all the outstanding issues identified in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer should be addressed appropriately. All safety systems and equipment are regularly checked and well maintained, and records of all tests/checks are kept up to date. There are gaps in mandatory training for staff that includes fire safety training, first aid, health and safety, moving and handling, food hygiene and infection control. The Acting Care Manager and Registered Providers are aware if this deficiency and they are taking appropriate steps to rectify this situation shortly. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 2 2 X X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP28 Regulation 18 (1) Requirement There must be a minimum of 50 of care staff trained to NVQ Level 2 or equivalent so that people who use the service receive care from knowledgeable and skilled staff. (Previous timescale of 31/01/06 and 01/06/07 not met) The service users’ care plans must be reviewed at least once a month to ensure that any changes of need are identified and addressed. Timescale for action 31/08/07 2. OP7 15 (2)(b) 15/07/07 3. OP18 13 (6) All staff must receive adult 31/07/07 protection training to ensure that people who use the service are not at risk of harm or abuse. (Previous timescales of 01/09/06 and 01/05/07 not met) People who use the service must be provided with a range of social and leisure activities both indoor and outdoor of the home. The activities must be varied in range and appropriate, and in DS0000020843.V335785.R01.S.doc 4. OP12 16 (2) (m) and (n) 15/07/07 Woodhaven Residential Home Version 5.2 Page 27 accordance with the service users’ choice, preference and capacities. 5. OP31 8(1)(a) The Registered Providers must put forward a Care Manager for registration with the CSCI. (Previous timescale of 01/07/06 and 01/12/06 not met) Electrical installations and portable appliances must be tested regularly to ensure the safety of people using the service. Actions must be taken to ensure a consistent supply of hot water at a safe temperature. This is to ensure that people using the service enjoy a regular supply of hot water without the risk of scalding. (Previous timescale of 01/06/07). 7. OP38 18 Staff must receive mandatory training in respect of • Fire Safety • Health and safety • First aid • Food hygiene • Infection control in order to ensure the safety of people using the service. (Previous timescale 01/12/06 not met). Suitable floor covering must be provided in all bedrooms so that people using the service live in a pleasant and comfortable environment. The vacant posts of a day carer (36 hours per week) and a night carer (24 hours per week) must be filled as a matter of priority to ensure there are sufficient staff DS0000020843.V335785.R01.S.doc 01/07/07 6. OP38 23 (2)© and 23 (2)(j) 15/07/07 31/07/07 8 OP24 16 31/07/07 9. OP27 18 15/07/07 Woodhaven Residential Home Version 5.2 Page 28 to meet the needs of people using the service. 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 OP7 Good Practice Recommendations It is recommended that all service users’ care plans contain detailed goals, aims and objectives recorded, and details and quality of daily care recording should be improved. It is recommended that staff files are organised into sections for ease of reading It is recommended that the Manager completes the Dementia Care Mapping course as part of the home’s quality assurance system It is recommended that the Manager provide a written guidance to staff on dealing with service users when they display challenging/aggressive behaviour. It is recommended that the Registered Providers consider designating a suitable member of staff to act as Activities Co-ordinator in the home. People who use the service should have access to external grounds, which are safe sufficient, safe and appropriately maintained for them to enjoy outdoor activity. Quality assurance systems within the home should be developed. This should include publishing results of service users/relatives questionnaires and producing an action plan for development. The Manager should develop systems for determining the views of service users with dementia who are unable to DS0000020843.V335785.R01.S.doc Version 5.2 Page 29 2. 3. OP29 OP33 4 OP10 5 OP12 6 OP20 7 OP33 Woodhaven Residential Home verbalise their needs. Woodhaven Residential Home DS0000020843.V335785.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor Chapter House South Abbey Lawn Abey Foregate Shrewsbury SY2 5DE 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. 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