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Inspection on 05/09/06 for Woodheyes Residential Home

Also see our care home review for Woodheyes Residential Home for more information

This inspection was carried out on 5th September 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

Staff members appeared to be caring and promoted privacy, dignity and choice. The home was clean, hygienic and homely and premises are maintained to high standards. The manager is committed to providing an excellent service, staff respect her and relatives spoke highly of staff approach and disposition. The manager was described as "hands on". Commitment was demonstrated to assisting staff with communication difficulties to attend and complete training. The owner of the home is fully involved in the day to day running of the business and regularly meets with the manager to discuss home matters. Residents appear to be aware of who the owners is. Relatives are made welcome at anytime and encouraged to have role in their family members life.

What has improved since the last inspection?

The outcome of the last inspection held last year was good. The owner has employed a new maintenance person with responsibility for general maintenance, decoration, and gardening.

What the care home could do better:

The care plans could be more reflective of the diversity of individuals in order to meet their care in a way, which is appropriate to them as individuals. The medication policy should be updated to include management of errors, risk assessment and involvement of staff in nursing procedures such as administering insulin or steroid type creams etc. Medication administration must be improved to ensure that medication is given as prescribed and reasons for not administering medication must be fully recorded. Residents with Dementia must be provided with a regular programme of meaningful activities, which stimulate them, these activities should be appropriate to individual needs as identified during their assessment. It was recommended that an activities organiser or member of staff be nominated to provide regular activities. Staff should be made aware of the homes missing person`s policy and procedure. Risk assessments must be completed for safe working practises and the environment. The training programme should be developed to include adult protection (abuse) training. Comments made by residents`, relatives and staff included. "We go to be and get up when we want to" "the laundry is fine, my relative always looks clean and presentable which is important" " Staff are alright" "The home is always clean" " Staff help me choose my clothes" " The routines of the home are ok we do what we like really" " Visitors are always made very welcome" "We get all; information from the care plan and are encouraged to read them" " We have not had any abuse training other than induction/NVQ" " Meals are at a set time but there is some flexibility" " The manager is brilliant" " Routines are important"

CARE HOMES FOR OLDER PEOPLE Woodheyes Residential Home 231 Hinckley Road Leicester Forest East Leicester LE3 3PH Lead Inspector Mrs Gillian Adkin Unannounced Inspection 5th September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodheyes Residential Home DS0000001680.V310496.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. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodheyes Residential Home Address 231 Hinckley Road Leicester Forest East Leicester LE3 3PH 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) 0116 2387371 0116 2387398 Todaywise Limited Mrs Sheila Gladys Sheil Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (24), Sensory impairment (2) Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one falling within category SI (E) may be admitted into the home when there are two persons of category SI (E) already accommodated within the home. 17th November 2005 Date of last inspection Brief Description of the Service: Woodheyes Residential home cares for twenty-four older persons who have dementia, mental disorder and sensory impairment of both sexes over 65 years of age in a purpose built property situated on the main Hinckley road. The home is close to the city of Leicester where residents have access to a variety of facilities. The home is easily accessible for private and public transport. The premise consists of two floors accessible by use of the stairs and passenger lift. There are a variety of facilities in the home including a dining room and two lounges. The home comprises sixteen single bedrooms one without en-suite facility and four double bedrooms one without en-suite facility. A garden, which is secure, is situated to the rear of the premises. Ample parking is available for visitors. An experienced person who is registered with the Commission for Social Care Inspection and has a management qualification manages the home. The current fee rate is £ 311-£430. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was inspected against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over 8.5 hours and commenced at 09.00 am on 05/09/06. The registered manager was present during the inspection. The focus of inspections is upon outcomes for residents living at the home and obtaining their views of the service provided. This process considers whether the home meets the National Minimum Standards and highlights areas, which might need further development or improvement. The method of inspection used is called “case tracking’ which involved selecting three residents and tracking the care they received this was achieved by discussion with them, their relatives and associated staff. Residents were selected randomly and represented people with diverse needs and a sensory impairment. During this inspection a tour of the rooms (occupied by those case tracked) and associated communal and external areas took place and the inspector viewed internal records, and care plans. Discussions and feedback were held with the owner of the home after completion of the inspection. Overall outcomes for residents appeared good however concerns were raised over the provision of meaningful activities and some concerns regarding risk assessments, medication management. (See requirements) What the service does well: Staff members appeared to be caring and promoted privacy, dignity and choice. The home was clean, hygienic and homely and premises are maintained to high standards. The manager is committed to providing an excellent service, staff respect her and relatives spoke highly of staff approach and disposition. The manager was described as “hands on”. Commitment was demonstrated to assisting staff with communication difficulties to attend and complete training. The owner of the home is fully involved in the day to day running of the business and regularly meets with the manager to discuss home matters. Residents appear to be aware of who the owners is. Relatives are made welcome at anytime and encouraged to have role in their family members life. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The care plans could be more reflective of the diversity of individuals in order to meet their care in a way, which is appropriate to them as individuals. The medication policy should be updated to include management of errors, risk assessment and involvement of staff in nursing procedures such as administering insulin or steroid type creams etc. Medication administration must be improved to ensure that medication is given as prescribed and reasons for not administering medication must be fully recorded. Residents with Dementia must be provided with a regular programme of meaningful activities, which stimulate them, these activities should be appropriate to individual needs as identified during their assessment. It was recommended that an activities organiser or member of staff be nominated to provide regular activities. Staff should be made aware of the homes missing person’s policy and procedure. Risk assessments must be completed for safe working practises and the environment. The training programme should be developed to include adult protection (abuse) training. Comments made by residents’, relatives and staff included. “We go to be and get up when we want to” “the laundry is fine, my relative always looks clean and presentable which is important” “ Staff are alright” “The home is always clean” “ Staff help me choose my clothes” “ The routines of the home are ok we do what we like really” “ Visitors are always made very welcome” “We get all; information from the care plan and are encouraged to read them” “ We have not had any abuse training other than induction/NVQ” “ Meals are at a set time but there is some flexibility” “ The manager is brilliant” “ Routines are important” Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 7 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. Woodheyes Residential Home DS0000001680.V310496.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 Woodheyes Residential Home DS0000001680.V310496.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Core standard 6 does not apply to this home. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. Prospective residents are assessed before admission to ensure needs can be met by the home. No intermediate care is provided. EVIDENCE: All of the care plans tracked contained evidence of an assessment of needs; the manager had conducted this. The manager said that she involved the relatives wherever possible in any assessments undertaken. Assessments were of a good standard and included a social history where this was obtainable. Relatives spoken with indicated they had been involved in the assessment. Residents were unable to clarify their involvement in the process. The manager said that no other assessments are undertaken other than the Social Workers assessment. It was agreed with the manager that it might be beneficial to reassess a resident after a period in and before discharge from hospital to see if any needs had changed. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 10 Woodheyes Residential Home DS0000001680.V310496.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are treated with dignity and respect and needs are met by the production of a care plan. Outcomes would be better if risk assessments were updated more often and medication management improved. EVIDENCE: All residents tracked were registered with a local General Practitioner, the owner and manager stated that they were in discussion with the practice to establish a regular surgery in the home, details had not been finalised. Community nurses provide nursing care such as dressings etc All residents had a care plan (information about how they would be cared for) in place. Care plans overall were of a good quality and descriptive of care required, however they were not fully reflective of the diversity of individuals which would enable staff to meet their care in a way, which was appropriate to them, this would include preferred lifestyle and activities. (see std 12) Evidence was provided of the care plan review monitoring system in place, this ensures that documents are current. Some reviews were not up to date and Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 12 the manager said she was working with a new deputy to ensure this was completed regularly. Risk assessments were in place in plans but in one instance where weight loss had been identified no risk assessment had been completed. Another plan of care included good evidence of weight monitoring and nutritional need on the risk assessment but had not been reviewed since June 2006 despite significant weight loss and sufficient evidence to indicate that the person concerned was at risk of developing a pressure sore. The care plan included information about equipment required including a pressure-relieving cushion, which on observation was not in place. A member of staff informed the inspector that they offered choices and that it depended on how the resident felt if she had the cushion. This was fully discussed with the owner and manager; the manager stated that a cushion was on order and that sufficient spare cushions were available for staff to use in the meantime. It was recommended that the manager actively observe equipment being used by staff to ensure it corresponds with the care plan. Daily records had been completed, and staff spoken with were aware of the contents of plans and how to deliver care required, although responses to certain behaviours appeared to be more of a pacifying nature. Other professionals and family had been involved in the care plan and this was evidenced by signatures and through discussion with them. Records seen indicated that usually medication was administered appropriately, however records of the residents tracked in one instance were inaccurate and indicated that a medication (paracetamol) had been administered. Blister packs were inspected and it was noted that the medication was still in the pack; furthermore there was confusion over when sennokot had been administered. Where a resident had refused or did not require a medication there was no identifiable reason on the medication chart (annotation). The manager was unable to clarify the reason for these errors and agreed to take up the matter with the staff concerned. The home assist district nurses with provision of nursing type procedures such as minor dressings, insulin administration, application of creams (steroid) however staff remain under the supervision of the District nurses. The medication policy was seen and the manager said it was due to be updated and it was recommended that the policy include management of errors, risk assessment and involvement of staff in nursing procedures such as administering insulin, eye drops creams etc. Medication administration must be improved to ensure that medication is given as prescribed and reasons for not administering medication must be fully recorded. Discussion with the manager indicated that there was a specific ordering procedure and that a number of staff had received or due to receive training in Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 13 this process. Training records seen indicated that staff had received medicines training or had been booked on courses. Comments received from residents’ and their relatives indicated that all staff in the home are respectful and tolerant and respect individual privacy and dignity. The inspector witnessed good examples of this. End of life decisions are covered in the residents care plan. Woodheyes Residential Home DS0000001680.V310496.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ experience elements of choice and control over their lives, and some flexibility with routines. Social and recreational needs would be better met if activities were provided each day, which suited the needs of the individuals concerned. EVIDENCE: Discussion with the registered manager and observation of records demonstrated that entertainers are organised for residents regularly. However on the day of inspection no activities were taking place. Currently no activities organiser is employed at the home and activities on the manager’s admission are more on an ad hoc basis. A programme of activities was advertised but was not consistent with what was happening. Observation of residents in the lounges indicated that some lacked stimulation and most were watching the television, which was on in both lounges. Some music was being played at the same time in the main lounge. A visitor stated that they considered provision of activities “could be improved” One resident was observed wandering without obvious reason and it appeared she was looking for something to do. Some residents in the home are sensory impaired and so watching TV was not a suitable activity. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 15 Discussion with staff indicated that one resident required significant attention and on discussion with her stated she wanted to go out more. Staff stated they attempted to deal with this by including her in coffee breaks outside which she enjoyed. None of the care plans seen detailed any specific plans to manage these needs. Residents with Dementia must be provided with a regular programme of meaningful activities, which stimulate them, these activities should be appropriate to individual needs as identified during their assessment. It was recommended that an activities organiser or member of staff be nominated to provide regular activities. The home manager said that she had not taken advice from other professionals such as the Alzheimer’s society about meaningful activities but intended to do so. Discussion with relatives and some residents confirmed that relatives were viewed as an important and integral part of their lifestyle and were encouraged to visit and made very welcome. Community links are maintained by a visiting hairdresser, regular church services, external entertainers etc. Discussion took place with the manager and cook about meals, and the menus for the home were provided. Menus appeared nutritious and offered good choices and what appeared to be a well balanced diet. Alternatives were not detailed on the menu and this was recommended. The manager said that finger foods are available in order to manage those residents who may not / cannot sit for the duration of a meal. A visitor was observed assisting her relative with their midday meal, she said the home encourage this. The resident appeared to be enjoying her daughter’s involvement. Nutritional care plans were in place and regular monthly weight recordings were seen. Discussion with the cook and observation of food for the midday meal indicated that fresh vegetables are used and many desserts /cakes are home made. Discussion with the owner indicated that there were plans to move the kitchen to make it larger in the near future. Meal times are set and most residents said they were happy with these arrangements. few residents were able to comment on the flexibility of routines however those able to indicated that there was some flexibility. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are protected from abuse and supported to make complaints, outcomes might be further improved if policies were developed and training provided regarding protecting adults from abuse. EVIDENCE: Staff and relatives spoken with were aware of the management of a complaint. Residents were unable to make comment. A key worker system is in place in order to build up confidence with a particular staff member. Advocacy details were seen on display but it was apparent through discussion that relatives were the advocate for most residents. The complaints file was viewed and indicated that only one complaint had been received by the home since the last inspection. Records seen did not indicate any outcome and no evidence was found to confirm if the complainant was satisfied with the outcomes it was recommended that any complaint be finalised formally in writing to ensure the complainant is satisfied with the outcomes. Discussion with the registered manager took place regarding a missing persons policy, this was due to the inspector case tracking a resident who had previously gone missing whilst out with family. Discussion with the resident indicated that they would still like to go home and staff confirmed that the resident constantly talked of going home. The policy could not be located however the owner said that all policies were being updated including this one. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 17 Upon discussion with senior staff it was apparent that appropriate action would be taken, but that staff did not know what the policy required. The grounds surrounding the home are secure and doors are alarmed. Staff should be made aware of the homes missing person’s policy and procedure. A number of staff in the home have achieved a qualification in care (NVQ level 2) and others are registered on the course. This course covers management of abuse. Staff spoken with had a good awareness of what constituted abuse and how to manage any incidents they considered to be abusive. Policies and procedures relating to abuse are in place but were in need of updating. Staff were aware of these policies through their induction. The current training programme was seen, the programme did not include adult protection, although some staff said that they had watched a video it was strongly recommended that more formal training be provided for staff. A relative made comment about the approach of staff and considered they spoke to residents appropriately and with a friendly disposition.. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.26 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. Resident’s benefit from living live in safe and well maintained premises, the home is clean and hygienic ensuring health and welfare is protected. EVIDENCE: During this inspection one resident was case tracked with specific issues relating to sensory impairment and the environment. A tour of the bedrooms and communal areas associated with this resident took place and after discussion with her and observation of the location of facilities it was evident that facilities provided met with this persons specific needs. The rooms of residents tracked were noted to be clean, hygienic, homely and well-equipped most bedrooms containing items of a personal nature. One resident said that they were particularly happy as the toilet was in their bedroom and easy to access. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 19 The home employs a full time maintenance person who has responsibility for all aspects of maintenance and decoration. The home appeared to be well maintained including external areas. The manager and owner said that he had a list of jobs to do each day as identified by staff; staff confirmed work was always completed. The owner schedules additional work such as decoration. Some residents in the home have dementia/ confusion and two residents tracked had evidence in care plans of wandering and being independent with mobility. The two people concerned were able to show the inspector where their room was and had en-suite facilities. No obvious signs other than health and safety signs were seen in the home, Discussion took place around the use of signs and symbols and their value in homes with confused or dementing people. The owner stated his intention to develop the home and he agreed that he would be seeking advice regarding the environment. The laundry was not inspected on this occasion however discussion with a relative indicated that laundry was of good quality and that residents always had their own clothes on. They also stated that the home was always clean. Good quality bedding and linen was seen on beds and in the dining room. Staff spoken with and training records seen indicated that infection control was covered during induction. Rosters inspected indicated that there were always two staff on duty Monday to Friday for cleaning and one at the weekend, Staff informed the inspector they were not required to undertake day-to-day cleaning. They were observed wearing appropriate gloves and aprons whilst undertaking toileting and feeding tasks. It was confirmed by observation of records that maintenance records do not currently include random water temperature monitoring. The owner and manager stated that all water outlets are fitted with thermostatic valves, but would re-instate random sampling which would be recorded. Residents are protected from risk of burns by the use of radiator guards which were observed in place. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. The needs of residents are safely met by thorough a robust recruitment and selection process and adequate numbers of suitably skilled and trained staff. EVIDENCE: Staff rosters were seen and a calculation of hours undertaken, the home are meeting the Department of health’s recommended numbers of care hours and are exclusive of manager hours. The manager and staff said that limited agency staff were used and most shifts are covered internally by permanent staff. Discussion took place with the manager about how hours were calculated, it was apparent from this discussion that dependency monitoring was not a feature of calculating staff hours. The registered owner indicated that he used the recommended guidelines as a base for calculating staff hours but would rely on the manager to inform him of any shortfalls in meeting needs / staff numbers. Rosters seen indicated that two waking night staff are on duty every night. The owner /manager said that monitoring of night staff takes place. One service user spoken with but not tracked said that staff come promptly when the call bell is used and also at night. Adequate staff were observed when residents required assistance such as with meals or walking. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 21 Relatives spoken with said that there was always adequate staff and lounges were never unattended. The registered manager stated that a key worker scheme was in operation this ensured staff got to know residents well. Staff confirmed the system and their roles as a key worker. The manager stated she had just completed the registered managers award (a course for managers) and had completed dementia training (seen in staff file) Staff spoken with said that the manager assisted them when required and provided hands on care; this was witnessed during the inspection. A deputy manager has been put in place since the last inspection to ensure that management duties are completed. Rosters (work schedule) seen indicated she was currently working alongside the manager to gain experience. Staff spoken with informed the inspector that they had received training this year. Although further training including adult protection (abuse) and disability awareness and equality and diversity was recommended. The manager stated that the home can do so many free courses each year and that last year moving and handling and safety compliance and safe handling of medications was completed. The manager discussed her role in helping a staff member with communication difficulties to achieve a qualification in care. A training plan was provided demonstrating a variety of training planned for this year including fire, dementia and medication management. A new member of staff discussed their induction called “skills for care” with the inspector. Staff files inspected indicated that staff had received training and that most had achieved their NVQ level 2/3 (recognised training in care) One member of staff had undertaken the training to teach staff moving and handling and another was due to commence the course. The manager stated that she conducted face-to-face interviews. Staff files were inspected and found to contain essential information such as police checks and references etc. Staff application forms include an equal opportunities monitoring statement. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33.35.38 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. The positive leadership of the home and well-supervised staff ensures that resident’s best interests and rights are promoted. Identifying risks in the home and production of risk assessments would protect their safety and welfare. EVIDENCE: The person in charge of the home is an established manager who is registered with the Commission for Social Care Inspection. Discussion with the manager indicated that she had just completed the registered manager award and undertook training to ensure she remained competent. The owner of the home provides a good level of support this was witnessed during this inspection. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 23 Staff and relatives spoke highly of the manager and the support given by her. Formal supervision of staff is conducted, staff stated, and records seen supported this. “Staff said the manager was supportive and had an open door policy” Annual appraisals of staff are conducted this was evidenced on staff files seen. Quality assurance was discussed with the manager and owner and an annual satisfaction survey is completed by the home each year, this had been completed this year. It was recommended that the results of the survey be analysed and the action to be taken (if any) be publicly displayed in the home. It was also recommended that the owner/ manager consider obtaining views of other people such as social workers and GPs regarding their views about the home. Policies were provided by the home relating to resident’s finances, the manager said that the home kept minimal amounts of money on behalf of residents. Where a large amount of money were concerned that a bank account would be set up. None of the residents tracked during this inspection had money held by the home? The registered manager provided a health and safety policy, which was due to be updated. Accident records were inspected and were found to be in order and monitored by the registered manager. General risk assessments for safe working practises and the environment were not in place and this was fully discussed with the owner and manager these assessments must be completed for safe working practises and the environment urgently. All fire records seen indicated that regular drills and training takes place, staff confirmed that they had received training in moving and handling and fire practice. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 24 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 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement Timescale for action 30/09/06 2 OP38 13(4) Medication administration must be improved to ensure that medication is given as prescribed and reasons for not administering medication must be fully recorded Risk assessments must be 30/10/06 completed for safe working practises and the environment. 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 Care plans could be more reflective of the diversity of individuals in order to meet their care in a way, which is appropriate to them as individuals. This should include meaningful activities. The medication policy should be updated to include management of errors, risk assessment and involvement of staff in nursing procedures such as administering insulin DS0000001680.V310496.R01.S.doc Version 5.2 Page 26 2 OP9 Woodheyes Residential Home 3 4 5 OP18 OP38 OP18 OP12 or steroid type creams etc. Staff should be made aware of the homes missing person’s policy and procedure. The training programme should be developed to include adult protection (abuse) training. An activities programme should be delivered each day and be reflective of the residents needs. Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodheyes Residential Home DS0000001680.V310496.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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