Inspection on 04/08/08 for Woodhaven Residential Home

This inspection was carried out on 4th August 2008.

CSCI 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 21/07/09

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 09/11/2008.

CARE HOMES FOR OLDER PEOPLE Woodhaven Residential Home Beacon Way Walsall Wood Walsall West Midlands WS9 9HZ Lead Inspector Peter Dawson Unannounced Inspection 4th August 2008 08:30 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.V369356.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.V369356.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 Manager post vacant Care Home 30 Category(ies) of Dementia (30) registration, with number of places Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 55 years and above Date of last inspection 26th April 2007 Brief Description of the Service: Woodhaven provides personal care and accommodation for up to 30 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 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 £364.00 - £405.00 per week for residency at Woodhaven. Woodhaven Residential Home DS0000020843.V369356.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 on one day from 8.30 a.m. – 5.00 pm. There were 20 people in residence with 10 vacancies. The National Minimum Standards for Older People were used as the reference for the inspection. The home provided an AQAA (Annual Quality Assurance Assessment) which they are required to complete by law. This was returned to us prior to the inspection and some information from that document is included in this report. Six written surveys were returned directly to us from 3 relatives and 3 staff members. During the inspection there were discussions, privately and together, with residents, visitors and staff. Some information and comments from those discussions are included in this report also. There was an inspection of the environment including a sample of the 30 bedrooms. During the course of the inspection 3 care plans were inspected in detail. Other records included medication, staff records and rotas, training records and other documentation relevant to the inspection. Throughout the day several residents were spoken with and those able to express a view said that they were happy with the service provided and made positive comments about the staff who support them. Two visiting relatives were seen and similarly made positive comments about the home, the Acting Manager and staff – some of their comments are included in this report - there was general satisfaction with the care being provided at Woodhaven. Two relatives raised issues concerning provision of more activities and residents going to hospital alone, these were discussed with the Acting Manager and Area Manager in the final feedback about the inspection. The inspection was conducted with Nicola Smith, Acting Manager and Karen Cartwright, Area Manager joined us for the feedback at the end of the inspection. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Eight requirements were made at the time of the last Random inspection on 16/10/07 and have all been addressed and are included in the following areas of improvement: The number of NVQ trained staff now exceeds the required 50 level. There are 4 people waiting to commence training and some have moved to NVQ3 study. There has been adult protection training since the last inspection and there are planned, arranged, confirmed dates for the remaining staff to complete this training. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 7 Application has now been made to register the Acting Manager as the Registered Manager, she is to be interviewed soon. New pumps have been fitted to the heating system to ensure a constant supply of hot water at safe temperatures for residents. Statutory training for staff in Fire Safety, Health & Safety, First Aid, Food Hygiene and Infection control has been ongoing and the few outstanding gaps filled with confirmed, arranged training courses. Activities provided for residents have improved considerably. An Activities Coordinator has been appointed and a varied range of activities established to meet the choices, preferences and needs of the residents. This should be continued. Floor coverings have now been replaced in all bedrooms and improved presentation and continence management. Previously vacant care staff posts have been filled. Several new staff have been appointed since the last inspection. A care plan to address the needs of residents with challenging or aggressive behaviours has been put into place. The quality assurance system has been developed to seek the views of residents, visitors and wider range of other professionals visiting the home. The home has a policy procedure relating to Equality & Diversity, this encompasses all areas of operation including residents, visitors, staff recruitment and care practice. All staff have attended Equality & Diversity training. What they could do better: When it is established that food and fluid intake needs to be monitored, charts should be completed on a daily basis and monitored by senior staff to ensure hydration and well-being. Any deficiencies should be referred to and shared with the GP. Regular weighing of residents is important and where there are nutritional deficiencies/weight loss, those residents should be weighed more frequently to ensure close monitoring of their condition. Although residents now have a good private chiropody service, it is important to retain the NHS service for those unwilling or unable to pay for this service. Review the system for recording hourly checks of residents throughout the night to ensure that their safety is maintained. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 8 Any event in the home which affects the well-being or safety of residents must be notified to CSCI under Regulation 37. Development of external visits/contacts for residents should be further developed and the garden area used to maximum benefit during the good weather. 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.V369356.R01.S.doc Version 5.2 Page 9 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.V369356.R01.S.doc Version 5.2 Page 10 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 – 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good pre-admission procedures, assessments and information available, ensure that prospective residents are able to make an informed decision about the suitability of the home. EVIDENCE: There is a Statement of Purpose and Service Users Guide, readily available in the home for residents and visitors. It was updated in June, contains all required information and is in pictorial form with good presentation. All residents have a copy in their bedrooms. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 11 Current fees should be included in the Statement of Purpose/Service Users Guide. The Statement of purpose states that the NHS Chiropody service is available every 3 months. This is not the case. A private chiropody service is available, this should be stated including the fees for the service. An option to use the NHS service should be retained for people unable/unwilling to pay for the service. Contracts are provided for all residents - a sample of two were seen that covered all the information needed and had been signed and dated at the point of admission. Pre admission assessments seen in records, had been carried out prior to admission in the persons current environment. They were comprehensive and contained all the required information. A letter is then sent to the prospective resident informing them that the home is able/unable to meet their needs based upon the assessment. The home does not offer intermediate care. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 12 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 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements made in care planning and medication records ensure that the personal and health care needs of residents are known and met. EVIDENCE: A sample of care plans including recently admitted and longer-term residents were seen. Information was comprehensive and detailed. Following a pre-admission assessments a further re-assessment takes place and is recorded after 1 week. Care plans are then reviewed monthly. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 13 Thereafter there are 6 monthly reviews for self-funding residents and 12 monthly for those funded and reviewed by the Local Authority There are assessments for nutrition, waterlow (propensity for pressure damage), plans to address specific areas of healthcare need such as diabetes, epilepsy, aggression – plans were in place covering all aspects of daily living. Healthcare records showed diagnosed conditions and interventions of all healthcare professionals. Plans are established where behavioural needs are identified with assessment and instructions for staff in dealing with any ongoing incidents. There are weekly checks for any pressure damage for all residents. None of the residents in the home have pressure damage at this time. Pressure relieving equipment is provided by the District Nursing Service when risk assessments indicate people are at risk. Social histories are completed in the form of a biography compiled by staff with residents and relatives. Individual social and recreational needs are identified and met wherever possible. There is a daily record of activity for each person. A spiritual needs assessment form is completed. All have a weekly wellbeing assessment score. Risk assessments are in place for moving and handling and other aspects of daily living. In records seen relatives had signed care plans and risk assessments where residents were unable to do so. Care plans seen had all been reviewed on a monthly basis. The care plan for a person who was ill in her bedroom on the day of inspection, showed a rapid physical deterioration in the past 2 weeks. Daily notes showed she had not been “eating or drinking” over the past few days and a food and fluid intake chart established as a result. Food had not been accurately recorded and there was no record of daily fluid intake. The Acting Manager will put these in place and ensure that intake is recorded and monitored on a daily basis. There had been previous weight loss for this person who had been weighed in the previous month but the date not known. It is important to ensure that where there are concerns about weight loss, weekly weighing and recording is essential to closely monitor changes in condition. The GP had seen this person and food supplements been prescribed. There are clearly good working relationships with the 4 GP practices visiting the home and the District Nursing Service who are presently visiting one resident weekly for dressings to foot wound. The Acting Manager felt able to approach either GP or District Nurse if she had any concerns on healthcare matters and was confident of a swift and positive response. Daily recording was generally good with the exception of recording night care. Hourly checks of all residents are carried out. Recording of checks and interventions were inadequate – recording did not follow the format established in the night records and there had been no recording of checks from midnight on the night prior to the inspection. Improvements are needed. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 14 The medication system was inspected. All staff currently administering medication have completed the Safe Handling of Medication external course and the homes assessments of competence carried out and in place. Two members of staff administering medication had not provided sample signatures and initials to identify the administration of medication and this should be completed. Risk assessments were seen in care plans relating to medication and none of the current resident group is considered able to self-administer medication. There are weekly and monthly checks (seen) of the medication system by the Acting Manager and the Pharmacist checks the medication system every 3 months. Records relating to medication received, administered and leaving the home were good and accurate. This confirms the view expressed in the AQAA (Annual Quality Assurance Assessment) that “Medication practices within the home have improved greatly since the last inspection”. The AQAA also states that over the past 12 months “ we have been updating our documents and improving them continually, putting into place a lot of good practice documents. We have improved our documentation in relation to care planning and risk assessments so that they are more in depth and individualised than they were before” – this view is confirmed in the documentation seen during this inspection. The home clearly have worked hard to improve in this area. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 15 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 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A range of activities has been established and can be built upon to meet individual social needs and improve quality of life for residents. EVIDENCE: At the time of the last key inspection on 26.4.07 a requirement was made to provide an appropriate range of indoor and outdoor activities to meet residents choices, preference and capabilities. At that time social and recreational activities were poor. Considerable progress has been made. The Deputy Manager became responsible for activities. An Activities Co-ordinator was appointed and a structure programme established. Care plans now identify social and leisure needs, entertainment is provided on a monthly basis, music/movement Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 16 provided 2 weekly. Activities are now identified for individual residents and recorded individually as they occur. Access to the local community has commenced with some residents taken to local shops or walks, staffing clearly limits the extent of this. The appointed Activities Co-ordinator is currently on maternity leave returning the responsibility for activities to the Deputy Manager and care staff who are attempting to maintain the momentum established. All residents have diagnosed dementia, many like to wander within the building and able to do so in safety. There is a small external garden area to the rear of the home with seating which the Acting Manager says is used on goodweather days – there are photographs to confirm this. The area was a little overgrown an in need of attention during the day of this inspection. There is a very large tarmac car park, presently unused which is to be converted into a garden area with safe access. Estimates are presently being sought for this work although this will clearly not be completed this year. The home and the present small garden area are safe, all external doors alarmed and good level access to the garden. A resident did leave the building some months ago and found wandering in a nearby town, she had been reported missing and eventually returned safely to Woodhaven. She left by a door which is alarmed but was not operating effectively at the time. This was quickly addressed and regular checks continue to ensure operation of all alarmed areas. A relative in written feedback said in relation to care and support “May sometimes have to wait due to staff availability” and in relation to activities they were arranged “sometimes - but more would be nice especially for more able-bodied residents. Also more outdoor activities and exercise”. Residents’ preferred lifestyles, likes, dislikes and choices are assessed and recorded. Most residents use the lounge areas during the day but some do access their bedrooms. Rising times are flexible, many residents having breakfast at 8.30 but others rising later. One resident rose at 12.00 saying she had “stayed in bed later because she was tired” and would now have her breakfast – an example of flexible routines and choice. A resident without relatives or visitors is being referred to the Independent Advocacy Service. His bedroom is particularly bare with no personalisation. It was suggested that the home should provide some personalisation of his room to establish some individuality and more homely presentation for him. Two visitors were seen during the inspection and spoken with privately. One visiting her father who has been resident for 2 years, says she visits twice each week and the rest of the family on the other days. She said the family were very satisfied with the way staff support him, they are kept informed of any changes in his condition and staff are always respectful and “wonderful” with Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 17 him. There are regular reviews in the home, which the family are invited to and attend. She considers Woodhaven provides “excellent” care. Another visitor whose relative has been a resident for several years said that he was highly satisfied with the care she receives and “wouldn’t want her to live anywhere else”. His relative has been admitted to hospital several times recently, he is always informed but on one occasion when he was contacted, he was out of the area and unable to go to the hospital with her. She therefore went alone. There has been a recent change to contracts (which he did sign) stating that the home would generally be unable to escort people to hospital due to the staffing implications. He says this is a change from previous practice; he was informed but is concerned that his relative should be escorted to hospital if he is unable, in exceptional circumstances, to be with her. This is a difficult area for the home to manage and they will consider the comments made. All have social care plans with good detailed information that is reviewed and updated regularly. Residents and visitors said that they were satisfied with the quantity and quality of food. Nutritional needs, choices and preferences for eating are known and recorded. Staff were seen to support residents during mealtimes in a sensitive way. Mealtimes were observed to be unhurried and residents seemed relaxed in the dining room. The mid-day meal was well presented and looked appetising. Some had meals on over-chair tables in the lounge area others had breakfast in their bedrooms due to healthcare needs. A choice of hot dish or salad was provided for the lunchtime meal – all had the hot dish although staff said that sometimes people do choose salad. When asked, several residents all said that they liked the food and had no complaints. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 18 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 – 18 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are acted upon and training for all staff in the protection of vulnerable adults will ensure that residents are protected. EVIDENCE: There is a complaints procedure in place, available in the home for residents and visitors. A copy of the complaint procedure is in the Service Users Guide, a copy of which is in all bedrooms. Two domestic type complaints have been received directly by the home and dealt with appropriately. Three complaints have been received by us. Two were referred to the providers for investigation. One related to care practice, healthcare and protection and dealt with by means of a Random Inspection on 16/11/07 and was not upheld. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 19 Another complaint was received by us and referred to the providers for investigation – this related to a member of staff sleeping on nights, inadequate staffing and poor staff morale. This was upheld in relation to sleeping on nights – a retrospective allegation but true - with no disciplinary action taken at the time due to poor/inappropriate legal advice given to the provider at that time. The third complaint related to alleged poor care whilst on a period of respite care. This was investigated and was not upheld. A requirement was made at the time of the last inspection to provide training for all staff in the Protection of Vulnerable Adults (Safeguarding). Training has taken place since the inspection and a programme of training for remaining staff was provided during this inspection. This included dates with confirmed bookings for the remaining staff to complete. This did not include recently appointed staff. This will be closely monitored by the home and CSCI. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 20 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 – 26 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improved decoration, maintenance and renewals have improved the environment, further planned improvements will ensure that residents enjoy a good standard environment. EVIDENCE: A requirement of the last report to provide suitable floor covering in all bedrooms has been addressed. All bedrooms and communal areas now have washable flooring (vinyl). This also includes all corridor areas. This enables good continence and odour management throughout the home but means that Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 21 some areas can look cold or bare. This is particularly so in the long corridor areas and it is important to try and “soften” those areas with decoration and improved décor. The ground floor corridor areas have been redecorated since the last inspection and work commending on the first floor corridor areas. Some small photographs to identify bedrooms have been removed and should be replaced soon. A resident with memory loss, using the lift to the first floor faced the daunting prospect of deciding which of the 12 bedrooms on the long corridor area was hers. Improved signage and more homely presentation in some areas would improve the facilities for residents who all have dementia care needs. There is one main lounge area on the ground floor, recently redecorated, comfortably furnished and well presented. There are also seating areas near the reception/lounge areas and a separate dining area, also used throughout the day. There are two small communal areas on the first floor, one a quiet lounge/hairdressing room, the other a games/activity room. Communal space is adequate. A requirement to provide adequate safe supplies of hot water to resident areas was made at the time of the Random Inspection, this has been resolved with installation of new water pumps, random tests during the inspection confirmed this. As mentioned previously in this report the small garden area to the rear of the home needs attention to improve presentation. Whilst all bedrooms have vinyl flooring the AQAA does state that if residents wish to have carpets they can discuss this with the owners. It is perhaps important to make this clear in the statement of purpose. All bedroom furniture is in very good condition and there are comfortable chairs also. Planned landscaping of the large rear car park will provide a pleasant garden easily accessed by residents. This will greatly improve the external facilities. The security system is good, with CCTV to protect the home and external and entry areas. 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. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 22 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 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made and robust plans to complete staff training will ensure better outcomes for residents. EVIDENCE: Staffing levels quoted in the last 2 inspection reports are related to higher occupancy. These have been reduced to meet the needs of the current 20 residents. The home employs 3 Care staff during the daytime one is a Deputy or Senior Carer – plus the Manager whose hours are supernumerary. At weekends 3 carers are on duty. There are 2 carers on duty at night. This is adequate for the present number (20) of residents. When working the Activities Coordinator is additional to those hours and there are adequate numbers of support staff including domestic, catering, laundry maintenance and administration. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 23 Three requirements relating to staffing were made in the last report - to increase the number of NVQ trained staff which was below 50 . Fill 2 vacant posts and provide statutory training for staff in fire safety, health and Safety, first aid, food hygiene and infection control. The number of NVQ trained staff now exceeds the required minimum of 50 . Only 4 staff are presently waiting to commence NVQ training, some have commenced NVQ3. Vacant posts have been filled eliminating the need for agency staff. Absences are generally covered by existing staff. Mandatory training has been provided since the last report and some staff are booked on courses – firm bookings with dates/names provided during this inspection. This will complete all required training for staff, with the exception of 4 who have commenced work in the past few months and been involved in induction training. They will be booked onto courses in the near future. There have been pockets of resistance to training by few staff; a firm line taken and managers state that if training is not taken as planned/arranged then disciplinary action will be taken. The AQAA states, “We have and still are working on gaps in mandatory training”. Two staff files were inspected. Induction was evidenced and POVA/CRB checks obtained prior to employment. All other documents required under Schedule 2 were present. Signed contracts were also in place. Questionnaires returned to us prior to the inspection indicated that all were satisfied with the support and supervision they received. They felt that induction and ongoing training was sufficient to ensure they had the necessary skills to meet residents’ needs. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 24 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 and 35 – 38 were inspected on this visit Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Temporary management arrangements have met the needs of residents and the quality of the service is improving. EVIDENCE: The home has been without a Registered Manager for the past 2 years. Requirements have been made to make an application for a Registered Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 25 Manager. This has now been done and the present Acting Manager is due to be interviewed for approval of registration two weeks following this inspection. The Acting Manager has been working in the home for the past 2 years and has worked hard to meet the repeated requirements and to improve areas of care planning, recording, staffing and practice. She is keen to improve standards further and is flexible and approachable. This interim management has been adequate and supported by the providers and Area Manager. The Acting Manager has shown competence in her management of the home. A good Quality Assurance monitoring system is in place, which includes questionnaires to residents, relatives and visitors including District Nurse, Hairdresser, Optician, Dentist Pharmacist and GP – 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. Efforts have been made to hold regular relatives meetings. Unfortunately there is very poor attendance (only 2 attended the last meeting) but the home will continue to arrange them in the hope of a more positive response. A complaint about a member of staff could have been handled better with hindsight but was based upon poor legal advice at the time. The changed Legal Advisor indicates a more robust response to matters of staff discipline. It is also important to notify us as required under Regulation 37 of any event which adversely affects the well-being or safety of residents. A system is in place for staff to receive formal supervision at least 6 times per year, although on a staff file seen this had not taken place for 4 months and appeared the exception. The homes record keeping is to a good standard. Improvements have been made in this area following external training for all staff. Woodhaven Residential Home DS0000020843.V369356.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 3 18 2 2 2 3 3 2 2 3 3 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 2 3 X x 2 3 2 Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 27 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 OP8 Regulation 12(1) Requirement Timescale for action 04/09/08 2 OP8 12(1) 3 OP38 37(1)(e) The service must make sure that people receive sufficient nutrition and fluids to keep them well. Where a problem is identified action must be taken to closely monitor residents’ healthcare that includes accessing appropriate health care support and detailed record keeping. (This relates to a person identified) Where there are concerns about 04/09/08 weight loss the service must take action to closely monitor the person’s condition, including appropriate health care intervention and detailed record keeping. (This relates to a person identified) Any event which affects the well- 04/09/08 being or safety of any resident must be notified to CSCI to enable us to monitor the safety of residents. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 28 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 3 Refer to Standard OP8 OP8 OP18 Good Practice Recommendations Check and review the system for recording hourly checks of residents throughout the night to ensure their safety is closely monitored Ensure the free NHS chiropody service continues to be available for those residents unable/unwilling to pay for a private service. Ensure the schedule of staff training booked over the next 3 months is undertaken. This will ensure staff have the necessary knowledge & training to protect residents. Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Woodhaven Residential Home DS0000020843.V369356.R01.S.doc Version 5.2 Page 30 - 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. 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