Inspection on 05/09/07 for Woodhill House HFE

This inspection was carried out on 5th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Woodhill House HFE 24/07/08

Woodhill House HFE 28/06/06

Woodhill House HFE 05/01/06

Woodhill House HFE 02/08/05

Woodhill House HFE 24/01/05

Woodhill House HFE 09/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodhill House HFE 60 Woodhill Lane Morecambe Lancashire LA4 4NN Lead Inspector Ms Jenny Hughes Unannounced Inspection 5th September 2007 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 Woodhill House HFE DS0000033118.V343122.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. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodhill House HFE Address 60 Woodhill Lane Morecambe Lancashire LA4 4NN 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) 01524 423588 01524 832981 julie.bagger@careservices.lancscc.gov.uk Lancashire County Care Services Julie Peirson Hagger Care Home 44 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (16) of places Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home with nursing - Code N, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places 16) Dementia - Code DE (maximum number of places: 28) The maximum number of people who can be accommodated is: 44 Date of last inspection 28th June 2006 Brief Description of the Service: Woodhill House is a purpose built two storey home, located a short distance from the centre of Morecambe, with its shops and the seafront. It is at the end of a quiet cul-de-sac, overlooking the local cricket ground. There is space to park cars both at the front of the building, and in the car park provided at the side of the home. An attractive central courtyard provides seating and tables for residents, and other smaller outdoor areas provide the same. The home provides personal care for older people, including people with dementia, and also provides nursing care to people with dementia. It is equipped to suit the needs of its residents. For example, there is a passenger lift to the upper floor, grab rails, raised toilet seats, assisted baths, and ramps for easy access. All of the rooms are single rooms, and toilets and bathrooms are conveniently situated, with some rooms being ensuite. There is ample communal space, with dining and lounge areas in each section of the home, some overlooking the cricket ground through the large windows. A designated area is provided for people with dementia, with sufficient communal areas within this, and access to outside space. There is also a designated area for those people with dementia who require nursing care, again with communal areas, and access to outside space. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 5 Staffing is provided over 24 hours, every day of the year. As at 5th September 2007, the fee scale ranges from £342.50 to £507, with additional charges for hairdresser visits, and extra newspapers and toiletries requested. More information regarding fees is available from the manager. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit to the home, in that the owners were not aware that it was to take place. The site visit was part of the key inspection of the home. A key inspection takes place over a period of time, and involves gathering and analysing written information, as well as visiting the home. The length of the visit was for 7 hours. Every year the registered persons are asked to provide us with written information about the quality of the service they provide, and to make an assessment of the quality of their service. We use this information, in part, to focus our assessment activity. Surveys were sent and received from residents and their relatives, and staff from the home. Reports have been received from the provider every month, following their monitoring visit to the home, giving information on how they think the home is performing. During the site visit, staff records and resident care records were viewed, alongside the policies and procedures of the home. The manager, residents and care staff were spoken to, along with visitors who called during the day. Their responses are reflected in the body of this report. A tour of the home was made, viewing lounges, dining rooms, bedrooms and bathrooms. Everyone was friendly and cooperative during the visit. What the service does well: The manager makes a pre-admission assessment, with a visit to the prospective resident at home or hospital. Care plans show staff the best way to look after each person. A key worker is allocated to each person, and daily records are made. “My mother is very well cared for. The staff are very good”, commented a relative on a survey. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 7 The home has some long-term experienced staff who work with good practices and attitudes. Training of staff is ongoing. All staff look smart and professional in their uniforms. Visitors are welcome at any time, with plenty of communal space available to have private chats. Meals are home-cooked, with well-balanced choices. They are well presented, with meal times being pleasant and unrushed. A resident said, “They will make you what you like. I said I liked salads and they make me one specially now. They come and ask you the day before what you want off the list”. The home is clean, bright and fresh; a warm and comfortable place to live. What has improved since the last inspection? What they could do better: The home could make sure the information given to prospective residents is actually what happens at the home, by regularly reviewing the contents of that information. The systems for passing on information about the care of residents to staff could be improved, to make sure all are up to date about people’s needs. The numbers of competent staff on duty could be increased to make sure the right support and supervision is given to residents, and to be able to offer opportunities for people to live fulfilled lives. Health and Safety and Infection Control issues need to be addressed when using care staff to carry out laundering and kitchen tasks, due to having no laundry or kitchen assistants. This practice needs to be addressed, as it affects the numbers of staff available to care for residents. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 8 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. Woodhill House HFE DS0000033118.V343122.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 Woodhill House HFE DS0000033118.V343122.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 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear assessment procedure, which is carried out for all residents. This means that the service provided is tailored to an individual’s needs and preferences. EVIDENCE: The Statement of Purpose and Service User Guide for the home are clear, and describe the service and what it should provide to each resident. They should be reviewed to make sure the content agrees with what the home is able to provide. For example, they state that there are various activities for all residents, and regular outings. There was evidence of only minimal activities for people due to low staffing levels. It also states there is a Registered Mental Nurse (RMN) on duty at all times, and although a qualified nurse is rota’d to be on duty, they are not always an RMN. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 11 Individual records are kept for each of the residents, with a set procedure for admitting someone to the home. Four selected files showed assessments had been received from social services or the health authority. These are needed so that the manager can confirm that the staff in the home are able to give the appropriate care, before it is decided that the home is the right place for the person to be admitted to. The manager needs to ensure this also includes whether there are enough staff to provide that care. Admissions should not be made where staff numbers are not high enough to match the needs of the person. The manager then makes a more detailed assessment, which covers the person’s routines and choices. This can include information on chosen times to rise and retire, how mobile they are, any dietary needs and cultural needs, and any hobbies and interests they may have and wish to try and continue. This is completed from discussion with the resident and their family, and signed, to make sure the information is accurate. A new system of assessment and care planning (called Saturn) is being introduced, and presently new residents are assessed using this system. This will be viewed at the next visit, when it has been used over time, and judgements can be made on the quality of the information it provides. Staff generally felt that the information about resident needs was not always passed on as well as it could be, either about new residents, or any changes in longer term residents. The manager said that information was available for staff to read, and a handover session should take place between shifts, when information is passed on. Response from a relative said that she felt her mother was well cared for, and the staff were very good. Woodhill House HFE DS0000033118.V343122.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, 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. The staff have a very good understanding of the residents’ individual health and personal care needs, but lack of staff numbers may cause these to not be fully met. EVIDENCE: Individual care plans are available, which identify the strengths, needs and goals of each person, so staff know how best to look after people. A night profile of each person shows what care is needed overnight. There is plenty of relevant information held about each person to enable staff to provide the right care, although the way it is held in individual files does not always make it easy to find the latest information. The manager said the new care planning system should help the information ‘flow’ more easily. This will be viewed at next visit. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 13 Reviews of the care are done every 1 to 2 months. On the files viewed, care plans were not always updated following the review, although the review may have noted a change in the care required. Staff spoken to were aware of the care needed by each person, but felt that the passing on of new information was not always efficient. It was not clear whether risk assessments had been reviewed at the same time as the care plans. The individual files are kept on each of the three units, and key workers make daily entries. One care plan viewed showed evidence of a record of good interventions for staff to use after identifying the behavioural problems of a resident. An awareness of the personal dignity of residents was evident in the care planning. A GP called at the time of this visit, and the resident was helped to her room to see him in private. Discussion with staff confirmed that they were aware of the individual needs, and specialist needs, of the residents, and records of visits by health professionals were kept on the files. Residents said that staff always contacted the doctor as soon as they thought a resident was a bit unwell. “I’ve got a chest infection at the moment, and they got the GP in and everything and I’m going to the hospital next week. They sort it all out, they’re very good. It’s the same group of girls who work here, I know them all”, commented a resident. One qualified staff was busy on the ground floor of the dementia nursing unit, providing nurse support to individuals, while two residents remained on the upper floor with no staff monitoring them, as care staff were also busy on the ground floor with residents. Staff were aware of residents needs, and abilities, but were unable to carry out the monitoring tasks required through lack of numbers. The manager should ensure there is always enough staff to provide the care, support and supervision all residents need. One resident liked to stay in bed “I always had to get up early for work, so it makes a change to be able to have a bit of a lie-in doesn’t it? “ She was encouraged to help herself as much as possible, and enthusiastically started getting ready to move to the lounge. A staff member was beckoned using the nurse alarm, to help the resident, who was on the second floor where there was no staff presence, with the response taking several minutes, as all the carers had been occupied with other tasks on the ground floor. The residents on this unit have various forms and levels of dementia, and staffing levels should reflect the need for provision of a higher level of care and supervision, and the fact that the unit is on two floors. Medication was stored in lockable trolleys, based on each of the units. Records were clear and up to date. A spot check of the records showed a couple of omissions with no reason given, and the manager needs to ensure audits of Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 14 medication records takes place at very regular intervals to pick up on any errors, and monitor staff performance. Staff assisting with the administration of medication had all been trained. Woodhill House HFE DS0000033118.V343122.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, 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. Meals were nutritious, and mealtimes relaxed, which encourages residents to enjoy food and mealtimes. There are limited social activities, meaning that people are not being provided with stimulation, and not being given the opportunities to live lives that are as fulfilled as possible, EVIDENCE: The individual care plans include information on each person’s life history, their religious needs, and which hobbies and activities they prefer. The manager confirmed that there was no general activities programme in place, and each unit’s staff decided what was to take place, dependent on what residents felt like doing each day. Staff said, “It is difficult. You have to see who wants to do anything first, but we do try to do something, even if it’s just sitting talking, or watching a film together, or maybe a manicure.” Other staff said that residents on their unit were very difficult to motivate, although they had been on a trip out, and had a Strawberry Fayre in the summer. One resident liked to garden, and a greenhouse had been set up for Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 16 her to enjoy, although lack of enough staff to supervise while she was there meant it had not yet been used. The hairdresser calls every week, and a church service is held in a lounge, for all to attend. A church service took place during this visit. Following lunch, staff were arranging for people to have baths rather than plan activities, “It’s the only time to get the baths done”, commented a staff member. People were generally seen sitting in the lounges through the day, the staff trying to chat and pay individual attention to residents while performing care tasks elsewhere. A relative had commented, “The staff are very good, but it’s a pity they seem so short staffed and so do not have enough quality time with the residents”. The manager needs to ensure staff are available to provide the improved stimulation and motivation planned for all residents, as recorded in the homes own assessment document. Staff address any diverse and individual needs in order to make sure each person is cared for equally, and feel as much at home as possible, but the care provided has become very task orientated rather than person orientated due to limitations of staff numbers and time. Visitors are welcome at any time, and two new visitors said they were made to feel welcome, and sat in the lounge with their friend who lived at the home. The manager owns a dog registered as a PAT dog, and residents enjoyed his company as he visited them around the home. All of the rooms contained the personal possessions of the residents, from pictures and ornaments, to small pieces of furniture. Some files contained records of these, and the manager should make sure records are kept of all personal belongings. The meals are planned on a 3 week menu, and the cook spoken to said that something different is offered if a resident doesn’t like the choice. The cook visits the residents to make sure they like what is on the menu, and a record of any special diets are kept in the kitchen. A resident said, “They will make you what you like. I said I liked salads and they make me one specially now. They come and ask you the day before what you want off the list” The meal this day was roast chicken, followed by peaches and cream or stewed rhubarb. The dining areas in the units are pleasant, small and homely, using small tables for four or six people to sit at. Meals are transported from the main kitchen to these dining areas in heated trolleys, where they are served piping hot and fresh to the residents from the mini-kitchens based there. Woodhill House HFE DS0000033118.V343122.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): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their families are generally confident their concerns will be listened to and acted upon, but lack of complete records could mean some issues are not addressed. Staff have an understanding of Adult Protection issues, which protect residents from abuse. EVIDENCE: There is a complaints procedure in place, which is clearly outlined in the service user guide, and which is on display in the home. The home’s self-assessment stated that a record is kept of all formal and informal complaints, including outcomes. However, the manager said that she had kept no complaints record which could be viewed, and was therefore advised to keep such a record as a useful tool to use as an overview of how the home is operating, and of any patterns emerging. The manager said there had been two complaints since the last inspection, which are linked to some behavioural problems of residents. One had been concluded to the satisfaction of the complainant, and the area manager was presently dealing with the second. The home’s self-assessment stated there had been one complaint. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 18 Several compliments sent to the home were seen, in the form of cards and letters from relatives. Residents spoken to said that they “would tell the staff”, if they were unhappy about something, and during the visit were seen to be confident in telling the staff what they wanted. The staff spoken to knew what to do if a resident or relative had concerns about the home, although not all had been instructed formally in the procedures when they started working at the home. Staff have training in the Adult Protection procedure, and what to do if they had any concerns. All staff attend abuse awareness training. Woodhill House HFE DS0000033118.V343122.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): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well maintained environment, which provides aids and equipment to meet the care needs of the residents. It is a pleasant, safe, and homely place to live. EVIDENCE: The home is modern, bright, airy, and a very pleasant environment to live in. There are various safe garden areas for residents to sit in the good weather, with the back of the home overlooking the local cricket pitch. Some residents enjoy watching the summer matches. A water feature is planned for one of the areas for residents to enjoy. Corridors are light, with windows along the length, and large plants and strategically placed seating giving a comfortable feel to this building, which has Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 20 its living units linked by these long corridors, and so is spread over a large area. The lounges in each unit are comfortable and welcoming. The bedrooms are also modern and bright, with new furniture and matching bedding and curtains. Residents are welcome to bring personal belongings, and small pieces of furniture if they wish, to help make their room their home. “Oh yes I like my room. I like to sit in there sometimes and watch the telly”, said a resident. “It’s grand”, commented another. Random viewing of the rooms showed them all to be clean and tidy. There are toilets and bathrooms around the home, some with assisted baths. General aids such as hoists, raised toilet seats, ramps and handrails help people with mobility problems, although some of the aids cannot be used in a bathroom which is too small, and toilets which are arranged in such a way that staff have difficulty in helping some of the very dependent residents who now live at the home. Staff have brought these problems to the notice of management. The laundry area is away from the kitchen and dining areas, and staff are aware of infection control guidelines. However, there are no designated laundry staff in this large home, and care staff are presently working in the laundry as well as providing care to residents, including serving meals. This raises health and safety and infection control issues. Any maintenance needs are recorded and passed onto head office for them to allocate the work out. The fire extinguishers were being serviced at this visit. Woodhill House HFE DS0000033118.V343122.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): Standards 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. There is an experienced workforce, who are not allocated in sufficient numbers at all times in all areas of the home. This means that residents do not always receive the right level of support. EVIDENCE: Staff files showed the necessary recruitment checks are made to ensure the protection of residents. References and Criminal Records Bureau checks were available, and notes of the interview were made. New care staff are required to have full induction training, so they are clear on what is expected of them when they are carrying out their work. These were seen to be signed by staff and management when completed. New staff are provided with an Introduction to Care Skills pack, which they work through. Other training has been attended, such as dementia awareness, physical interventions, and fire safety, and information is available on areas dealing with such as diabetes, Parkinson’s disease, and incontinence. 27 of the 28 carers have achieved NVQ Level 2 or above. Generally, care staff said they felt they were being given training which was relevant to their role, keeping them up to date with new ways of working. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 22 Nursing staff have no induction training organised, and have commented that they have some concern over an understanding of their role, how the whole team of nursing and care staff work together, and communication amongst that team regarding residents care, or events taking place. The nursing unit has only been open for three months, but these issues should have been addressed prior to the opening. A staff rota shows who is on duty at any time. However the rota does not state that care staff are also carrying out kitchen and laundry duties, when they were seen to leave the units where residents were then being monitored by one less carer. As stated previously, this also raises health and safety and infection control issues. The home cares for very dependent residents, particularly in the dementia units, and must be staffed accordingly. Staff and relatives show concern over the lack of quality time, and the task orientated care rather than person orientated. “The staff are very good, but it’s a pity they seem to be short staffed and therefore do not have enough time for ‘quality time’ with residents” said a relative. “I feel the clients care is not as good as it should be. Not only are the clients needs not being fully met, but staff morale is low, which also effects the clients emotional needs”, said a staff member. As nursing is provided, there must always be a qualified staff on duty, day and night. It was noted that on 3rd September 07 there was no nurse on duty overnight. This means the home was operating illegally. There needs to be some contingency plan to cover unplanned absences of qualified staff. Information on the homes self assessment form shows that one selected week, the manager has provided the outstanding nurse cover over several hours, so removing her from her management role. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has a vision for the home that has not been effectively communicated to residents, relatives and staff. Not all staff are aware of their roles and responsibilities. EVIDENCE: The manager has worked at the home for seven months, and has been registered with CSCI since July 2007. She is a Registered Mental Nurse, having experience of working mainly with the elderly, with needs associated with different forms and levels of dementia. Her management experience has taken place mainly in the community. She is due to undertake the Registered Managers Award. Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 24 A survey response from a relative said that she thought the care staff were very good, and her mother was very well cared for. However, she commented that although she was very appreciative of all that is done, she feels that all of the comments she has made over the previous years about lack of staffing has made no difference, so wonders how much effect any of the ‘paperwork’ and consultation has on a resident’s care. Visitors called during this visit, and said that they were made to feel very welcome. The manager commented on the commitment of the staff who worked at the home, and how they helped all they could to enable rotas to be covered following the organisation’s guidelines. However, the rota’s do not allow for adequate supervision and monitoring of the very dependent people living at this home, where the constant presence of a carer in areas where residents are is needed. The manager has developed residents meetings to be held in alternate months, to listen to suggestions on how they feel the service can be improved. There is also now a relative support group, which meets on a monthly basis with the care assistants, to listen to any concerns. Regular visits are made by the Area Manager of the organisation, who monitors the care provided. Clear records are kept of anything to do with resident’s finances, and a safe is available if anyone needs it. One to one supervision of staff should take place every two months. However this has been affected by the lack of staff and the related time to do this. “I feel that we should be given more opportunities to discuss issues on a one to one basis, without feeling rushed” commented a staff member. Records show regular fire training for staff, although one staff stated that they did not have the fire procedure fully explained. All accidents are recorded, and in a general file, which gives good opportunity for an overview of any patterns emerging. Risk assessments are done, and what action to take. The new manager is presently introducing the new care planning system, and the result of this will be viewed at the next visit. Woodhill House HFE DS0000033118.V343122.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 3 X 3 X X X 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 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 26 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)(a)( b) 16(2)(n) 17(2) 13(3(16(2 )(j) Requirement The manager must make sure staffing resources are enough to make proper provision for the care of the residents. Activities must be developed to give people the opportunities to live fulfilled lives. A record of all complaints, and the action taken, must be kept. Health and Safety and Infection Control issues must be addressed where staff are cross working in care, laundry, and kitchen areas as part of a working day. The numbers of competent staff on duty must be appropriate for the health and welfare of the residents There must be appropriate training for all staff The registered person must ensure there is a suitably qualified registered nurse working at the home at all times. The manager must attain the Registered Managers Award The manager must help ensure safe working practices and make DS0000033118.V343122.R01.S.doc Timescale for action 30/09/07 2 3 4 OP12 OP16 OP26 30/09/07 14/09/07 30/09/07 5 OP27 18(1)(a) 30/09/07 6 7 OP30 OP27 18(1) (i) 18(3)(a)( b) 9(2)(i) 12(1)(a) 30/09/07 05/09/07 8 9 OP31 OP38 31/08/08 30/09/07 Woodhill House HFE Version 5.2 Page 27 proper provision for the health and welfare of the residents through appropriate staffing. 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 OP1 OP3 OP14 Good Practice Recommendations The information held in the Statement of Purpose and Service User Guide should be up to date and reflect what the home provides The manager should ensure a system is in place to confirm that full up to date information about residents care is passed onto staff A record of personal possessions should be kept for all residents Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Woodhill House HFE DS0000033118.V343122.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!