Inspection on 16/05/07 for Woodland Grove

This inspection was carried out on 16th May 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

Woodland Grove 29/11/06

Woodland Grove 26/01/06

Woodland Grove 08/08/05

Woodland Grove 30/03/05

Woodland Grove 16/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodland Grove Weston Park Bath Bath & N E Somerset BA1 4AS Lead Inspector Jon Clarke Key Unannounced Inspection 16th May 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 Woodland Grove DS0000008163.V337835.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 Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Grove Address Weston Park Bath Bath & N E Somerset BA1 4AS 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) 01225 464004 01225 426501 tina.davis@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust Tina Alison Davis Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 42 persons aged 65 years and over requiring personal care only. 29th November 2006 Date of last inspection Brief Description of the Service: Woodland Grove is a care home for older people owned and managed by Anchor Trust Foundation and provides accommodation for up to 42 residents. The home is a converted older property, which has been extended and adapted to provide residential care within individual flats. Each flat has a bed sitting room, small-integrated kitchen and en-suite bath or shower, basin and toilet. There is a large communal lounge, which can be divided into two rooms and a dining room with direct access to the patio seating area. There is lift access to all parts of the home. The home is set in extensive gardens and located in the Weston area of Bath within easy reach of the town centre and local amenities. Fees are £525 per week inclusive of all care and facilities in individual’s flats, not including community health services. Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home as part of an inspection which took place over two days. As part of this inspection I looked at a number of documents including care plans, staffing (recruitment, training) and health and safety. On the second day I was accompanied by the CSCI pharmacist inspector who examined the arrangements and systems in place for managing and administering medication. I had an opportunity to meet with a group of people who live in the home as well as talk individually to residents. I was also able to talk with a small number of staff. “Have Your Say” questionnaires were sent to the home before the visit: residents returned 14 of 25 sent; relatives returned 5 of 15 sent. The responses to the questionnaire have been used to inform the judgements made at this visit as to the quality of care provided in the home. What the service does well: There is a real effort on the part of management and staff to provide a homely, supportive environment where individuals have their needs met yet are able to retain their independence as far as possible. People who live in the home are given opportunity to voice their views and the manager and staff have created an open, friendly and welcoming environment. Of note is that people who live in Woodlands are able to exercise choice in their daily routines though this can lead to pressures on staff particularly evident in relation to mealtimes. Over 6 months there has been a period of change in the home initially there were staffing difficulties, concerns about the quality of care and low morale and real dissatisfaction expressed by residents of the home about the care they were receiving. I felt at this inspection that there was a distinct improvement in the attitude of staff who were very positive and there was a real sense of everyone working together. Of greater importance was that there was not the negative comments being made by residents, comments were: “I feel I am very lucky and happy to be here” “I am very happy here” “changing a lot for the better” Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 6 The manager and all staff are to be commended on the real and substantial improvements and efforts made to address the quality of care and staff issues which previous inspections have highlighted. An area I wish to highlight as real improvement is that of Health and Safety practice and procedures. There has been real improvement in this area reflected in the home being awarded the Anchor Home’s Safe Site Award. This is to be commended and staff who have responsibility in this area are to be congratulated in achieving this award reflecting their commitment to improving and raising standards in the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 7 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 Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to make an informed decision about its capacity to meet health and social care needs of prospective residents. EVIDENCE: A number of pre-admission assessments were looked at and showed that full and detailed information had been obtained as part of the admission process. Included was information about the individual’s health and physical wellbeing. In addition there is information about social history, likes and dislikes. Where individuals are known to the local authority a copy of the social services assessment is obtained. The home undertakes a Pre-Admission Assessment questionnaire and it is planned that this be further developed so that the quality of the admission process can be judged and where necessary improved. A comment from a Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 9 questionnaire “first impressions, very bright, warm and friendly conducted tour very instructive”. Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care Planning and arrangements for meeting health care are generally good providing staff with the necessary information so that the health and social care needs of residents are met. Arrangements for managing resident’s medication make sure that resident’s health needs are protected. The practice of staff and policies of the home help to make sure that residents are treated with respect and their dignity is upheld. EVIDENCE: A new format for care planning has been introduced over the past two months. Staff have received training in completing these new care plans. A small number, which had been completed, were examined. They provide a detailed and thorough outline of individual’s care needs. The central element of the care plan is the baseline assessment which gives information about physical health, lifestyle choices, support and daily care needs, emotional and psychological wellbeing. The care plans identified specific Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 11 and significant areas of risk which are task centred such as nutrition one risk assessment had been completed as result of concern about an individual’s risk of under nourishment. Also risk assessed are falls. Care plans seen had been signed by the individual and in one instance the individual had written their life history as part of the care plan. Individuals I spoke with confirmed that they had been involved in the completion of their care plan. In talking with staff they were positive about the new care plan approach and welcomed their introduction though felt initially they would be time consuming. However once the new arrangement is fully in place they have the potential to offer a good basis for the delivery of care in the home. A further inspection may be undertaken later in the year to examine in greater detail how this new system has been adopted and the progress made in their introduction. The health care needs of people who live in the home are met through the provision of community based health services such as chiropody, optician and dental treatment all available as required and on a regular basis. Community nursing service visit the home to provide “nursing” care to individuals where this is needed. The pharmacist inspector completed the following: Staff order all medicines used in the home through the pharmacy. Medicines administered by staff are supplied using a monthly blister pack system. No homely remedy policy is available in the home. It is recommended that staff look at developing a policy, which would enable residents to ask for a medicine for occasional minor ailments such as headache. Some residents look after their own medicines. Lockable storage is provided for this. Risk assessments are in place to make sure that residents are safe. These are reviewed regularly. Staff must make sure that this process includes all residents who self-administer medicines. One resident told me that that they looked after some of their own medicines that they use when needed, while staff administer the regular medicines. This was not documented in the person’s care plan and no risk assessment had been completed. Action should be taken to address this. All medicines seen were stored safely. A medicine fridge is available and the daily temperature recorded, these were in the appropriate range. A general Anchor medicine policy was available for staff. The manager said that a member of staff had looked into writing an additional policy giving more specific details of procedures used in Woodland Grove. This would be good practice to help staff in the safe handling and administration of medicines and action should be taken to complete this local policy. An update of medication training has been provided by the pharmacy recently and in-house procedures Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 12 also check that staff are able to give medicines safely. Residents spoken to said that they were happy with the way staff gave them their medicines. The pharmacy provides printed medicines administration record sheets each month. Those examined had been completed as required and provided an accurate record of medication administered to individuals. Some of the sheets appeared to include some medicines which were no longer prescribed. It is recommended that staff discuss with their pharmacist how they can make sure that only current medicines are included on the medicines administration record sheet. This is to make sure that it is clear from the record sheet which medicines should be administered and reduce the risk of mistakes being made. Records are kept of the receipt, administration and disposal of medicines. A new month’s medication had been received on the morning of this inspection. I checked the records of receipt, administration and disposal of some medicines from the previous month and these indicated that medicines had been given as prescribed. Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: The recruitment of an activities organiser has resulted in improved opportunity for people who live in the home to participate in a range of activities. Currently this is only a 17hr post however a further 17hr post is to be advertised. One individual I spoke to said there “was definitely more going on now we have Hannah (the organiser)”. Activities arranged include gentle exercise, film shows, sing-a-long, poetry reading, flower arranging and during summer months trips out one being Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 14 organised to Horseworld. There are also individual sessions arranged. It is planned that 3 programmed activities are held weekly. A daily coffee morning is held and once a week the manager attends. Respondents to the questionnaire said that there are “always” (2) “usually” (10) “sometimes” (2) activities arranged by the home that they can take part in. One individual commented that she would like to go out to bingo and a relative commented that their relative would welcome a walk around the gardens or outing to the village. In talking with staff there was a sense that their part in providing activities and spending social time with residents was limited due to the level of work demands. They have an important part to play in socialising with residents and this should not be limited to when they have keytime or are undertaking care tasks. The providing of activities should not be the sole responsibility of the activities organiser but shared by all staff as far as they are able and be encouraged to do so. Visitors are encouraged to the home and all relatives who responded to the questionnaire were positive about the care provided in the home. Comments included: “ provide a very caring and flexible environment” “a very good home run by a very caring and efficient staff” “communicate well with the people in their care” “staff very good at contacting us if there is a problem”. The home’s relative/visitors questionnaire also confirmed that the home offers a warm and inviting environment for visitors with all respondents saying they were greeted in a polite and courteous manner and were confident about approaching staff should they have any concerns. I noted that two of the questions on relative’s surveys related to their being aware of and encouraged to attend residents meetings! This is clearly a contradiction in that as named they are purely for residents and not others. It would be in my view inappropriate for relatives or others to attend these meetings. This was discussed with the manager and the possibility of holding a twice-yearly relatives meeting. In talking with individuals they spoke of the flexibility of staff and that they were able to choose “how I spend my day”. One individual said they were pleased they didn’t have to go to the dining room for their meals and there was no pressure on her to do so. Another person I spoke with said they like the home because “its up to me what I do and staff “always listen to what I say and want to do”. There were mixed responses from individuals when asked about the meal arrangements in the home. Whilst the majority were positive about the quality of meals provided there were a number of comments about the serving arrangements. Residents are given the option of having their meals in their Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 15 flats or in the dining room. On the first of day of my visit there were 15 individuals in the dining room and on the second day around 20. Individuals are given a choice at the time of meals being served other then those who choose to remain in their flats. Individuals said how they would like to know what was on the menu for that day and I discussed with the manager the possibility of menus being displayed in the home and on the tables. Lunchtime meal is served from 12:30 with those in the dining room having priority this means that those in their flats do not get their meals until later. This should be made clearer so that there is not the pressure or expectation from individuals that all meals are served at 12:30. There is also staffing pressures in that there are no clearly nominated staff who can remain in the dining room throughout the lunchtime period staff having to respond (rightly) to other demands which happen over the lunchtime period and outside of the dining room. There is also a kitchen assistant vacancy which the home has been unable to fill as well as a staff member on long term sick leave. Some of the comments from individuals reflect these shortfalls: “service is slow” “sometimes have to wait a while for meal to be served, food is not hot enough” “yesterday lunch was cold” On the day I joined residents there was clearly frustration from some individuals and the atmosphere in the dining room was not as I have previously experienced in that it was not relaxed but indeed quite stressful. In part this may have been due to the choice of meal in that as part of trying new dishes it had not been successful and individuals were rightly unhappy about the quality of the meal offered however staff and cook on the day responded well in giving everyone the option of another choice of meal. However on the second day visiting the home there was still clearly in my view not the atmosphere one would want at this important social part of the day. I discussed with the manager the possibility of recruiting a dining room assistant whose main role would be to support staff and remain in the dining room during all mealtimes. This would include breakfast when individuals come to the dining earlier then the time for breakfast and whilst efforts are made to give them breakfast the priority for staff at the time is to assist individuals in getting up. In addition the recruitment of a kitchen assistant whose role would also to be to assist in the dining room would help to ease some of the pressures on care staff which they also recognised and importantly lead to what has previously been a relaxing and unhurried experience for people who live in the home. In talking with the cook she is clearly making a real effort to provide a wide choice of appetising and enjoyable meals for residents and indeed there were a number of positive comments about the quality of meals: “I enjoy my meals here always a good choice” “I mostly enjoy the choice of meals” and “the food is normally very good”. Respondents to the Have Your Say questionnaire were that 2 “always” like the meals in the home 8 “usually” and 4 “sometimes”. I Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 16 also looked at the comment book available and again there were a number of positive comments on how much individuals had enjoyed the meals. Woodland Grove DS0000008163.V337835.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear procedures in place that enable individuals to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible residents are protected from harm by having policy and procedure about the Protection of Vulnerable Adults and providing training to all staff in this area. EVIDENCE: The home’s complaint procedure is available through the home’s service user’s guide and is also posted on the home’s noticeboard. When asked individuals were aware of their right to complain and all respondents to the Have Your Say questionnaire said they knew how to make a complaint. In talking with individuals about what they would do if they were unhappy about anything they all spoke of “telling staff” “I would definitely say something” importantly they felt staff would listen to what they had to say “and do something about it”. One individual said “staff very easy to talk to and staff are approachable”. There have been 11 complaints in the last 12 months records of these complaints were looked at and showed that the required action had been taken. All of the complaints had been responded to in writing within 28 days. Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 18 The home has an Adult Protection policy in place which sets out the actions to take in the event there are concerns about the welfare of an individual or allegation of abuse is made. The home has responded professionally and taken the necessary action when such allegation has been made. Woodland Grove DS0000008163.V337835.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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and hygienic environment for the residents and staff. People who live and work in the home benefit from a warm, welcoming and well-maintained environment. EVIDENCE: Following refurbishment of the home 12 months ago there have continued to be improvements in the home’s environment. These have included new dining room carpet and lounge furniture. Further improvements in the environment are planned over the next year including flats being fitted with new en-suite facilities, kitchenettes and carpets. Individuals I spoke to said how the home is always “clean and spotless”, respondents to the Have Your Say questionnaire said that the home is fresh and clean (10) “always” (4)” usually”. One relative commented “we feel the Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 20 home and grounds are well maintained and every effort is made to make it comfortable for residents”. Infection control procedures are in place and staff have access to protective clothing and anti-bacterial soap is available. It is planned to develop a new hand washing training programme as part of improving infection control in the home. Woodland Grove DS0000008163.V337835.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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements in the home are generally satisfactory so that the needs of residents can be met in an efficient way with care being provided by skilled and competent staff. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of residents is protected. EVIDENCE: Staffing rotas were looked at for the previous 4 weeks and showed that there were 3 staff on duty (am) with team leader, 2 (pm) plus team leader and 2 waking night. Staffing is adjusted according to level of occupancy and care needs in the home. When talking to staff they felt that staffing of the home had improved particularly in relation to employment of permanent staff members however they also commented that the needs of those that live in the home had also increased. When asked about response of staff one individual commented, “they are often short staffed” and another “think we are understaffed” and “not enough staff in the kitchen”. In response to questionnaire 2 stated “always” and 10 “usually” to ‘Are staff available when you need them?’ A relative commented, “sometimes more care staff are required to meet the residents’ demands”. Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 22 Staffing is an area the manager needs to continually review to make sure adequate staff are on duty at al times and the manager confirmed this takes place. NVQ training of staff is ongoing with currently 12 staff working towards NVQ 2. At present only 6 of 20 care staff have NVQ qualification. This fails to meet National Minimum Standard in that 50 care staff should be NVQ qualified. However if the current staff undertaking this qualification are successful this standard will clearly be met and exceeded over the next 18 months. Recruitment and selection records showed that the necessary checks had taken place ie Criminal Record and POVA (Protection of Vulnerable Adults) checks, two references obtained and application forms provided full and detailed information about employment history. Health questionnaires are also completed. Training records showed that staff had completed the required mandatory areas of training: first aid, moving and handling, health and safety, fire and Adult Protection. Staff complete the BTEC Intermediate Award Introduction to Care Work and BTEC Induction Certificate. Other training completed by staff included nutrition and dementia care however this was limited. An area identified by the manager for improvement is that of training around specific health care related to needs of people who live in the home. This would certainly improve the level of skill and knowledge of staff and is to be welcomed. Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good opportunities for residents and others to express their views about the service they receive. The practice of the home helps to make sure that the health, safety and welfare of residents and staff is protected. There is a failure to provide adequate and appropriate formal supervision to staff so that management can formally review and monitor their practice, look at performance and give staff the opportunity to express any concerns and discuss their professional development. EVIDENCE: The manager Ms T Davis has been in post since June 2006. From this time she has made considerable efforts to address the areas of concern associated with the quality of care in the home. On appointment, staffing arrangements were Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 24 poor with extensive use of agency staff and poor staff retention with low staff morale. Since that time there has clearly been considerable improvement with real effort and commitment to improve the quality of care at Woodlands. Alongside this has been improvement in staffing of the home with almost full complement of staff and clearly in talking with residents and staff the quality of care and staff morale has improved. This has been achieved not least by the enthusiasm and commitment of all staff in the home and is to be commended. In talking with people who live and work in the home there were very positive comments made about the manager: “she’s very approachable” (residents and staff) “we can talk to her” (residents), “she is doing well” “very much hands on” (staff). An area identified for improvement at the previous inspection was that of Quality Assurance through the use of questionnaires. The manager has now started on this process and recognises it is an area for further improvement over the coming year. Results of questionnaires sent to residents and relatives have yet to be collated and will be looked at the next visit however CSCI has requested information about the outcomes of these surveys. I was able to look briefly at some of the responses and they were positive with general satisfaction about the care though with some issues which would need to be addressed (In relation to Catering and Meal Times). Residents meetings are held monthly though with poor attendance at times only 6/7 individuals attending. This was discussed with the manager as to ways to encourage greater attendance one being to hold the meetings after lunch in the dining room. However they do provide an opportunity for people who live in the home to express their views about the service they receive and have done so with suggestions about the food in the home and activities. A residents’ catering meeting was also held which looked at the meals and menu provided in the home. A number of records (8) relating to formal supervision were looked at and showed there were significant gaps. In one instance an individual started in 06/12/06 and there was no record or evidence of supervision having taken place. In two other instances last recorded supervision meetings were 13/12/06 and 28/11/06. One individual who started 05/02/07 first supervision was recorded as 10/05/07. In talking with staff they could not recall their last supervision sessions. Health and Safety records that were looked at showed good practice in this area with through information about the areas relating to safety in the home. Fire Risk assessment had been completed and reviewed (15/11/06) with fire equipment serviced and maintained on a regular basis (last being 05/02/07). Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 25 Fire alarms tested weekly and emergency lighting monthly. Fire drills are held regularly with fire drills for night staff being held 19/01/07. Equipment such as hoists are serviced and maintained regularly (last being 29/01/07), (lift 13/10/06 & 08/01/07). Water system risk assessment completed 19/03/07 and annual inspection 06/10/06 with required action being taken to ensure water temperatures are within required range. Safety Data information (as part of COSHH – Control of Substances Hazardous to Health) is available for potential hazardous chemicals or materials used in the home such as cleaning chemicals and soap products. A generic home risk assessment which looks at the environment of the home in terms of potential risks to people who live and work there was completed 09/08/06. Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP36 Regulation 18 (2) Requirement The manager shall ensure that persons working at the care home are appropriately supervised. (This refers to the formal supervision of staff National Minimum Standard states that care staff receive formal supervision at least 6 times a year). Timescale for action 01/10/07 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. Refer to Standard OP9 Good Practice Recommendations Consideration should be given to developing a homely remedy policy so that residents can have treatment for minor ailments such as headaches. Staff should discuss with their pharmacist how they can make sure that only current medicines are included on the medicines administration record sheet. This is to make sure that it is clear from the record sheet which medicines should be administered and reduce the risk of mistakes DS0000008163.V337835.R01.S.doc Version 5.2 Page 28 OP9 Woodland Grove 3 OP15 4. OP9 being made. Arrangements for the serving of meals should be improved so that mealtimes are a relaxed, unhurried and enjoyable experience and offer people who live in the home an opportunity to socialise and enjoy this important part of the day. Action should be taken to complete the local medicine policy so that staff have information about procedures specific for Woodland Grove. Woodland Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AP 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 Grove DS0000008163.V337835.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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