Inspection on 15/09/08 for Woodland

This inspection was carried out on 15th September 2008.

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

Woodland 19/09/06

Woodland 23/11/05

Woodland 08/06/05

Woodland 07/01/05

Woodland 25/05/04

Woodland 15/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Maple Lodge

Polesworth Group 32 Station Road

Heathlands

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Woodland Trefonen Road Morda Oswestry Shropshire SY10 9NX Lead Inspector Rebecca Harrison Unannounced Inspection 15th September 2008 09:55 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 Woodland DS0000020692.V371833.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. Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Address Trefonen Road Morda Oswestry Shropshire SY10 9NX 01691 656963 01691 671225 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) Mr Steven Bol Mrs Catherine Leslie Heathcote Care Home 37 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (37) of places Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 37 Learning Disability (LD) 1 The maximum number of service users to be accommodated is 37. 2. Date of last inspection 19th September 2006 Brief Description of the Service: Woodland is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for up to 37 Older People to include one person with a learning disability. The home is situated in the village of Morda, close to Oswestry and has recently been extended providing an additional 17 bedrooms, all with en-suite facility. The nearby shop and pub are within walking distance of the home. The home makes their services known to prospective service users in a combined Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk Fees charged were not detailed in the Guide as required therefore the reader may wish to obtain more up to date information direct from the care service. Woodland DS0000020692.V371833.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 outcomes from the service they receive. One inspector carried out the inspection over six and a half hours. A range of evidence was used to make judgements about the service to include discussions with some people who use the service, three staff on duty, two visiting relatives, the manager and proprietor. We did a tour of the home, reviewed the homes quality assurance processes and observed the care experienced by people using the service. We received completed surveys from eight people who live at the home and surveys from three staff. A number of records were reviewed to include care records held on behalf of three people, complaints and protection, staff training, recruitment and health and safety records. Three people who live in the home were ‘case tracked this involves establishing individuals experience of living in the care home by meeting them, discussing their care with staff and visiting relatives, looking at care files and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was sent to the manager for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. The inspection reviewed all twenty-two of the key standards for care homes for Older People and the four requirements made at our last key inspection. Information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. We completed an Annual Service Review on 27th September 2007 and the report is available in the home. This did not involve a visit to the service but is a summary of new information given to us, or collected by us, since we did our last key inspection of the service on 19th September 2006. Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has been extended to provide 17 new en-suite bedrooms, bathing facilities and a large lounge. Improvements to the original part of the home have been undertaken for example both the kitchen and laundry have been refurbished, a number of rooms have been redecorated and some floor coverings replaced. All bedroom doors are now lockable, a new call bell system has been installed and blinds fitted in the conservatory. Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 7 What they could do better: The manager is very committed to both the people living and working at Woodland and has acknowledged that due to the rapid increase in numbers of people accommodated over a short period of time, it has proved difficult to manage the service to the best of her intentions. The manager may therefore benefit from additional support or dedicated time to assist her with fulfilling her role and responsibilities to deliver effective outcomes for people using the service. People living at Woodland have potentially been placed at risk because the service has not demonstrated that all of the required checks have been undertaken on new staff employed to make sure they are suitable before they start employment. Both the manager and proprietor committed to ensuring all of the required checks are undertaken with immediate effect to ensure the protection of people who use the service. The service should involve people using the service with planning for their care. Care plans require further development to ensure people living at Woodland receive their care how they prefer and ensure that they are supported by staff in a consistent manner. Opportunities for activities should be improved. Surveys that we received, discussions held and observations evidenced that the home needs to develop, in consultation with residents, a programme of activities and events from which they can choose. Staff should be provided with opportunities for training to ensure they have the necessary skills and knowledge to equip them to do their work. They should also receive formal supervision which is dedicated time set aside for staff to receive support regarding their work. Staffing levels need to be kept under review to ensure there are sufficient staff on duty and increase with occupancy in order to meet the assessed needs of the people living at Woodland at all times. Comments from surveys received include: ‘I would like more entertainment and trips out’ ‘More activities needed’ ‘Since I came here we have had a large and very attractive extension. Unfortunately the staffing levels have not as yet been increased to cope with the extra work. They are very busy and do not have the time to deal with the small needs as they did previously and which are so important. I think most complaints, mine and others, are due to this which is a pity’ Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 8 ‘We do not know the menu in advance so that I cannot suggest alterations until the meal is put before me’ 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. Woodland DS0000020692.V371833.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 Woodland DS0000020692.V371833.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): 1 and 3 (standard 6 does not apply to this service) Quality in this outcome area is good People looking for a care home can be confident that Woodland can support them. This is because information about the service is made available to help them make an informed choice about whether the home is able to meet their individual needs. An assessment of a prospective service users needs is undertaken or obtained and people are given the opportunity to visit the home to ensure the service is right for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People are provided with information about the service through the combined Statement of Purpose and Service User Guide. The document has been updated to reflect the increase in registered numbers and provides people with information to help them understand the services that Woodland provides. We Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 11 advised the manager to separate these documents and ensure the current fees charged and terms and conditions are detailed in the Guide as required. Two residents and a relative told us that they visited the home prior to admission and received enough information about the service to make an informed choice about the home, which were also the views of people who completed surveys for us. The number of admissions to the home has increased dramatically following a major extension and the increase in registered places. At the time of this inspection 34 people were living at the home. The home has an admissions procedure in place. Care management assessments are obtained where required and the manager stated that she undertakes pre-admission assessments as seen on files. One person was admitted outside of the home’s category of registration for a short period and this breach of registration was fully acknowledged by both the manager and provider who committed to ensure this practice does not occur in the future. Woodland DS0000020692.V371833.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): 7,8,9 and 10 Quality in this outcome area is adequate People living at Woodland have a care plan in place however these require more detail so that staff have all the information they need to ensure people get the care they need in the way they prefer and demonstrate that the person, or someone close to them, has been involved in the development of them. People who use the service are safeguarded by the home’s system for handling, storing and administering medication. The principles of respect, dignity and privacy are put into practice ensuring people are treated as individuals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at Woodland cannot be fully confident that they receive the care they need because their care plans lack detail about how they prefer their care to be delivered. For example the exact level of ‘assistance’ a person requires Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 13 with personal care tasks should be identified to ensure people receive care in a consistent manner. The three care plans sampled gave no indication of consultation with the individual concerned or their representative and were not completed using a person centred format. A falls risk assessment had not been completed for a person who has a history of falls, which led to hospitalisation before being admitted to the home. The care plan stated that the person requires accompanying when walking although we observed the person return to their bedroom without supervision following lunch. Assessments for risk such as nutritional and manual handling were available with evidence of review. Discussions held with a number of people who use the service evidence that daily routines are flexible in accordance with their individual’s preferences such as rising and retiring to bed. Records held for the people we ‘case tracked’ evidence that their health needs are regularly monitored and kept under review and that the home arranges for health professionals to visit as required as observed during the inspection. One person who lives at the home stated that they had seen their GP that morning, received the prescription and taken their medication. Appointments and outcomes are recorded on the records held on file. We spoke to two visitors who were very positive about the care their relatives receive and how their health is maintained. One relative said, ‘I am always told about any health issues straight away and my wife is well cared for here’. Medication procedures appeared satisfactory at the time of the inspection. The manager reported that only the managers, the deputy and senior support staff are permitted to administer medication and that they have undertaken training in the safe handling of medicines. Medication requiring refrigeration is currently stored in the general fridge in the kitchen and not held securely. Therefore we advised the manager to consider purchasing a dedicated refrigerator. The manager reported that she periodically observes staff administer medication and committed to undertake written assessments to measure their ongoing competence. Respecting people’s privacy, dignity and rights is clearly documented in the homes Guide and the self-assessment (AQAA) states ‘The personal care is provided by well trained and friendly staff, who show respect for the residents and ensure privacy and dignity at all times. The residents independence is maintained as far as is possible’. Observations made and discussions with people using the service indicated that this is upheld. The manager was seen to knock on people’s bedroom doors prior to entry during a tour of the home and one person spoken with stated ‘Staff always knock on my door and show great respect’ Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate People staying at Woodland are enabled to keep in contact with family and friends but may benefit from greater opportunities to develop and maintain their social and recreational interests so that they can lead their life in a chosen way. People who use the service receive a healthy, varied diet according to their assessed requirements but would welcome more choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On admission a ‘pen picture’ is obtained with the individual and those close to them which details their likes, dislikes, important people, former occupation, hobbies and interests. This helps to provide staff gain an overview of the person. One relative stated ‘I was very impressed that the home had taken time to find out my wife’s history’. People who use the service looked relaxed in the company of other people they share their home with and the staff caring for them. Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 15 Some people living at Woodland would welcome greater opportunities to partake in a range of activities, which was acknowledged as an area requiring improvement in the self-assessment (AQAA) completed by the manager. Currently the home does not provide a planned programme of activities for people to opt in of out of but musical activities from external sources are occasionally provided and a Christmas outing is to be planned. A mobile hairdresser visits weekly and people we spoke with indicated that they enjoy using the service. One person was taken outside for a short walk during the inspection and two people were out accessing a day service. Comments we received include: ‘There could be more activities offered’ ‘I would like more entertainment and trips out’ ‘We only have Bingo once a fortnight’. ‘Sometimes activities are arranged but this is difficult as there is such a wide difference in abilities and interests’ ‘Very few activities are made available’ Visitors are welcome to visit the home and are made welcome. We spoke with two visiting relatives who spoke very positively about the service provided. Comments include ‘I am very much made welcome, my wife is at home here and I’m always offered a drink’ ‘I visit regularly and am always made welcome, my wife is very content here’ ‘My family and I have visited the home many times and at different times of the day … and our perceptions have been that it is well run, the staff are kind, friendly and caring and the manager or her assistant are very approachable if there are any problems’. The self-assessment (AQAA) completed by the manager states ‘Woodland is run in such a way as to promote autonomy as much as possible e.g. residents can keep control of their finances and Residents informed about advocacy options…and have the choice of where to take their meals’ The meal served at lunchtime was well presented and we observed staff make the mealtime a social and enjoyable experience. Surveys identified the need to involve people with menu planning in order to keep up to date with changing wishes of people and to respect autonomy and choice. People told us: ‘Sometimes I like the meals, it depends which cook is on’ ‘The food is good’ ‘I would like more choice of meals’ ‘Individual likes and dislikes are catered for. It is excellent that fresh fruit is given when requested as a snack. Meals are nicely presented and served’’ Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 16 ‘There are a lot of things I can’t eat and while notice is taken of this there are so many people involved in serving a meal that it does not always work out except for tea. We do not know the menu in advance so that I cannot suggest alterations until the meal is put before me’ ‘I’ve yet to have a bad meal’ Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate People who use the service and their representatives are able to express their concerns and have access to a complaints procedure. Procedures are in place to safeguard people from potential abuse however newly appointed staff require training to ensure people are greater protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People we spoke with told us they know who to complain to if they are unhappy with the service they or their relatives receive. The home has a complaints procedure in place and this is available in the Residents Guide. We have not received any concerns or complaints since our last inspection and no complaints were found recorded in the complaints log and confirmed by the manager. One person told us ‘Any concerns or requests are always dealt with sympathetically’. The home has a copy of the local multi-agency safeguarding adult policy and procedure. No referrals under safeguarding adult procedures have been triggered since the last key inspection. Some staff have received training in adult protection and appraisals seen on the five staff files examined identified this as a training need therefore this needs to be actioned at the earliest opportunity, which the manager committed to do. One member of staff spoken Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 18 with reported that she has received training in adult protection and whistle blowing procedures and has ‘no concerns whatsoever’ regarding the measures in place to protect people living at home. The findings of this inspection evidence that people have potentially been placed at risk because of the homes poor recruitment practices, which is reported under the ‘staffing’ section of this report. Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good The environment has been extended and improved and provides people living at Woodland with a homely, clean and comfortable place to live where they feel safe and secure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has been extended to provide 17 new en-suite bedrooms, bathing facilities and a large lounge and registration for this was granted in February 2008. People spoken with during the inspection told us that they enjoy living at the home and that their rooms are comfortable. The home is fully accessible throughout and rooms seen were personalised with family photos and ornaments. Discussions with residents and visiting relatives evidence that people are benefiting from the improved facilities to include en-suite facilities to the new rooms, landscaped gardens and increased parking. Improvements Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 20 to the original part of the home have been undertaken for example both the kitchen and laundry have been refurbished, a number of rooms have been redecorated and some floor coverings replaced. All bedroom doors are now lockable, a new call bell system has been installed and blinds fitted in the conservatory. People are provided with a clean home which is free from unpleasant odours. Products hazardous to health are appropriately stored and the necessary assessments readily available. Staff receive training in infection control procedures as part of their induction. One relative stated in a survey ‘I am very impressed by standard of cleanliness everywhere, the bedrooms are always cleaned daily and nice and fresh, windows opened; bathrooms sparkling clean; communal rooms clean, tidy and comfortable’. Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor Staff work positively with the people they care for but greater opportunities for training would equip them with the skills and knowledge to meet the individual needs of the people living at Woodland. People using the service are supported by a committed staff team, however the lack of robust recruitment procedures has potentially placed people at risk of harm because the manager has not secured suitability of candidates before they have commenced working at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Throughout the inspection staff were accessible, good listeners and communicated well with the people using the service. They appeared motivated and committed to their work. Surveys we received and people we spoke with provided positive comments about the staff and management team. People said: ‘staff are very caring, always helpful and give individual attention’ ‘The staff are good listeners and work very hard’ ‘The staff and manager are great’ Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 22 The manager stated of the 26 care staff employed 13 hold a nationally recognised care qualification known as NVQ at 2 or above and 8 are currently working towards the award. The deputy manager has the Registered Managers Award and NVQ level 4 in Care and the manager is a Registered General Nurse and has also obtained the Registered Managers Award. The self-assessment states improvements for the next 12 months include ‘Recruitment of new staff to ensure adequate numbers in order to maintain our high standards, as the number of residents increases in the new extension’. Current staffing levels was discussed with the manager, people who use the service and visiting relatives. People told us there are usually enough staff on duty to meet people’s needs. Discussions with the manager evidence that additional staffing has been provided and she is aware of the need to keep this under review based on occupancy and the assessed need. The staff rota was an accurate reflection of staff on duty. In addition to care staff the home employs two part-time cooks, a kitchen assistant and part-time domestic. People told us: ‘There’s probably not enough staff at the moment’ ‘Staff are pushed at times’ ‘I sometimes have to wait to go to the toilet’ ‘Good ration of staff to residents and always somebody available when assistance is needed…’ ‘Unfortunately the staffing levels have not as yet been increased to cope with the extra work’ (for the increase in numbers of residents) The people living at Woodland have potentially been placed at risk because the homes recruitment process has not been robust. Files for five staff recruited over the last twelve months were examined and they failed to contain all of the documentation required by Regulation and the evidence the home provided in their AQAA. None of the files contained a staff photograph and application forms did not detail a full employment history. One file did not contain two written references as required and no CRB check had been undertaken. Another file contained a CRB but from a previous employer. Such shortfalls were fully acknowledged by the manager and provider and they committed to review the homes recruitment practices immediately to ensure people are not placed at risk in the future. Without an overall staff training matrix in place it proved difficult to establish the training staff had undertaken. No training certificates were available on the five files sampled however the manager reported that staff receive in-house training as part of their induction, that training in manual handling had been booked and that many staff require first aid training. Two of the staff spoken Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 23 with told us they had received training but other staff had only received induction. One person considered staff would benefit from receiving training in dementia care. All five files sampled contained an appraisal, which identified staff training needs to include manual handling, first aid and abuse. Woodland DS0000020692.V371833.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): 31,33,35,36 and 38 Quality in this outcome area is adequate People living at Woodland benefit from having a management team who are committed to meet their care needs however some systems are making people potentially vulnerable and action taken to improve processes will improve the overall quality of the service. Quality assurance requires further development to assess performance and evaluate outcomes for people using the service. The premises are maintained in a manner which ensures the safety of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 25 The manager of the home is a Registered General Nurse and has obtained the Registered Managers Award and is experienced and knowledgeable of the individual support needs of the people living at Woodland. People we spoke with were very complimentary about the manager and of her commitment to the service and felt the home is managed in the best interests of people accommodated at Woodland. Comments include: ‘Kate works miracles’ ‘The manager is very approachable and very good’ ‘The manager and her deputy are always around and easy to speak to’ ‘Kate is marvellous’ Satisfaction questionnaires have been distributed to people living at the home and people asked to comment on areas to include staffing, activities, food and décor. Comments seen in the completed surveys were positive overall. The manager committed to collating the responses and developing a report based on the findings to assist with future planning. Records of staff appraisal were available on the five staff files sampled and the manager has acknowledged the need to improve and provide structured staff supervision at the required frequency. This is dedicated time for staff to receive support regarding all aspects of their practice, the philosophy of care and career development needs. Arrangements for the management of people’s finances were discussed with the manager who stated that the home actively discourage taking responsibility for managing these and that families deal with this with the exception of one person. Records were available for the small amount of finances held however we advised the manager to obtain two signatures for all transactions. An agreement for money held on behalf of the individual should be obtained and how this is managed should be clearly documented in the persons care record. Secure facilities are provided for the safekeeping of money and valuables in people’s own rooms and people we spoke with confirmed they were satisfied with this arrangement. People living at Woodland are generally safeguarded by the health and safety procedures in place, for example certificates for the servicing of equipment are maintained and safety checks are undertaken at the required frequency and risk assessments for safe working practices have all been reviewed since the last inspection. Manual handling assessments completed for individuals using the service require further development for example the assessment seen for one person states ‘requires full sling hoist and two carers to attend’. The manager must ensure that staff receive mandatory training to include manual handling, first aid, fire etc at the required frequency to ensure they are fully equipped with the skills to carry out their roles and for the protection of people living at the home. The manager reported that there are no outstanding requirements made by the Fire or Environmental Health Officers. Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 26 Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 27 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x 3 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 2 Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 28 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 OP29 Regulation 19 Schedule 2 Requirement All pre-recruitment checks must be undertaken on new employees before they commence direct work. This will ensure people living at Woodland are protected by the home’s recruitment policy and practice. Timescale for action 15/09/08 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 People living at the home should be involved in drawing up their care plan, these should be more detailed and describe how all people’s needs in respect of health and welfare are to be met. This will support staff to provide care in such a way as to ensure all service users needs are met. A falls risk assessment should be completed at the earliest opportunity for the person identified as being at risk of falls to ensure they receive the appropriate support and monitoring. 2 OP7 Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 29 3 OP12 4 OP30 Greater opportunities for stimulation through leisure and recreational activities should be reviewed with people living at the home, which suits individual need and preferences. A staff-training matrix should be developed and an individual training and development assessment undertaken with staff which identifies their training needs and actual training undertaken. Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 30 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 Woodland DS0000020692.V371833.R01.S.doc Version 5.2 Page 31 - 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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