Inspection on 25/09/07 for Woodland Manor

This inspection was carried out on 25th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodland Manor 06/08/08

Woodland Manor 03/10/06

Woodland Manor 08/12/05

Woodland Manor 29/06/05

Woodland Manor 11/03/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Woodland Manor Whitton Park Thurleston Lane Ipswich Suffolk IP1 6TJ Lead Inspector Deborah Kerr Unannounced Inspection 25th September 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodland Manor DS0000060707.V352537.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 Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Manor Address Whitton Park Thurleston Lane Ipswich Suffolk IP1 6TJ 01473 461622 01473 462298 lesley.tournay-godfrey@anchor.org.uk keri.sherwood@anchor.org.uk Anchor Trust 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) Miss Lesley Tournay-Godfrey Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 One named individual to be accommodated with learning disability (LD) 3rd October 2006 Date of last inspection Brief Description of the Service: Woodland Manor is situated within Whitton Park and is set in extensive grounds. There is adequate parking to the front and the nearest public bus stop is a short walk from the home. The building is a large Victorian House, which has been extended to incorporate a three-storey block comprising two floors of care home accommodation. The ground floor of this block comprised a mixture of care home bedrooms and a privately occupied flat that was not part of the registered premises. The accommodation comprises 32 single rooms and 2 double rooms. Four single bedrooms were reported in the Statement of Purpose to be under 10m². There is also a large lounge with dining room adjoining. There is a further lounge/dining area near to the kitchen in the main house and two smaller quiet lounges in the extension. Anchor Trust has produced a colour brochure and compact disc providing detailed information about the home and the range of services and facilities. It also contains a copy of the home’s terms and conditions of residence and a copy of the complaints procedure. These are available on request and can be provided in large print and other languages. The home offers accommodation in the category of elderly people who require personal care. Each person is issued with a contract, which specifies their agreed fees and how much they are expected to pay on a weekly basis. Fees are calculated depending on the needs of the individual and range from £331.00 to £600.00 per week. This was the information provided at the time of the inspection, people considering moving to this home may wish to obtain more up to date information from the care home. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over nine hours on a weekday. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection, including information obtained from the Annual Quality Assurance Assessment (AQAA), issued by the Commission for Social Care Inspection (CSCI). Feedback about the service was also obtained from nine residents, six relatives and two staff ‘Have Your Say’ surveys. A number of records were inspected, relating to people using the service, staff, training, the duty roster, medication, health and safety and a range of policies and procedures. During a tour of the home, time was spent talking to eight people living in the home, four staff and a relative. The manager and administrator were both available and fully contributed to the inspection process. What the service does well: Woodland Manor continues to offer people a home that is comfortable, clean and which meets their needs. Fresh fruit and flowers are placed around the home, creating a pleasant and homely atmosphere. Feedback from relative’s surveys and discussions with residents confirmed that the staff provide a good standard of care. Comments included “Woodland Manor provides a happy and relaxed environment for the residents” and “staff look after me very well, I could not find a better place”. People using the service confirmed that they are able to exercise choice and control over their lives and that they are given the freedom to make decisions about how they spend their time. The catering arrangements continue to provide people with nutritious and balanced meals. People spoke highly of the food, comments included “the food provided here is extremely good” and “the food is lovely”. Examination of records confirmed that the home operates a good recruitment procedure. Staff are provided with appropriate training and support, which has enabled in house promotion and provides staff with the skills and experience they need to carry out their duties, to meet the needs of the people using the service. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A requirement was first made in October 2006 for care plans to be in place, which reflect the needs of people using the service. The home must set and agree a timescale for the new care plan format to be fully implemented. Information in these care plans must be accurate, kept up to date and reflect the individuals assessed needs and preferences. Where people living in the home are identified, at risk, for example, where a person has been assessed as a high risk of falls, action must be taken to ensure the risk of harm is minimised. There must be systems in place for tighter monitoring of the amount of controlled medication held at the home. Unused medication must be returned to the pharmacist. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 7 The programme of decoration and refurbishment needs to continue, in particular attention needs to focus on the laundry area and bringing the older part of the home up to the standard provided in the newer extended parts of the home. 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 Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6, People who use the service experience good quality outcomes in this area. People who may use this service are provided with information they need to make an informed choice about where they live and will be issued with a contract, which clearly tells them about the service they will receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA and verified at the inspection confirmed that people moving into the home are provided with a welcome pack, which gives clear information and helps people to understand the services and facilities offered by the home. The pack also contains a copy of the terms and conditions of residence and a copy of the complaints procedure. People spoken with confirmed they had been given all the information they needed before moving into the home, one person commented, “I am very happy with the process of moving into the home, I felt well supported”, another person said, “I am very happy here, I don’t have to ask, I get everything I want”. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 10 Prior to addmisssion people are given the opportuinity to visit before they make a decision about whether the home will meet their needs. They also have a thorough needs assessment undertaken, which focuses on establishing the individual’s health, personal and social needs. This includes ensuring that the facilities, staffing and specialist services provided by the home meet their specific needs. Information is gathered by a range of sources, which include other health professionals and assessments from placing Social Workers. A further assessment of the individual is carried out within twenty-four hours of moving into the home to assess the person’s current state of health and to ensure information obtained in the pre admission assessment is still correct. This information is used as a foundation to establish the person’s future care. Residents’ files examined reflected they had been issued with a contract and terms and conditions of residence when moving into the home. These were all agreed, signed and dated by the individual and/or their representative. Private paying residents were provided with information about their weekly fee and method of payment and date their fees would be reviewed. Similar contracts were issued to local authority funded people, which also provided information about their weekly contribution. Discussions with staff and training records reflect that staff are provided with good training opportunities to ensure they have the knowledge and skills relevant to their role and which meet the needs of people using this service. All new staff are required to complete induction training, which covers the basic needs and protection of people living in residential care and the role of the worker. Recent training has consisted of diabetes and dementia awareness, nutritional profiling, including healthier food and specialist diets. Team leaders have attended training to implement the new care plans, with a view to cascade training to all care staff. Discussion with a team leader and information provided in the AQAA identifies that further training is planned to link in with Speech and Language therapist to meet the communication needs of individuals affected by stroke(s). The home does not provide intermediate care. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11, People who use the service experience adequate quality outcomes in this area. People using this service can be assured that they will be treated with respect and dignity, however care plans do not currently ensure the health and personal care they receive is based on their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Anchor Trust has introduced new care plans, which have been designed to reflect person centred care. These are divided into eight sections, which cover all aspects of the individual’s health, personal and social care needs. The AQAA states these plans are to be used as a holistic assessment tool, starting with the needs assessment prior to admission, which will evolve as the needs of the person change. Examples of the new style care plans were seen, however the home is still predominately using the old style care plans with documentation from the former providers ‘Golden Days’. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 12 Three care plans of service users were examined as part of the inspection, two of these were in the new format. These were well organised, however some of the information recorded was inconsistent, which could lead to confusion about the individuals plan of care. For example, the pre admission needs assessment stated that an individual required two hourly night checks, however the care plan for sleeping and night care states they had requested 3 hourly checks. Some of the information being recorded did not fully reflect the level of care and support required by the individual. For example, the person’s mobility plan states that to help them improve their confidence and independence, their daily living skills, should be maintained, however no plan was in place to say what these daily living skills were or how they were to be maintained. Relevant health charts and assessments, relating to moving and handling, pressure care, nutrition and falls had been completed. Dates had been entered to reflect these were being reviewed to monitor and reflect the individual’s current and changing needs and where intervention is required. The AQAA stated that the specific health care and interventions and appointments are outlined in the blue section of the care plans to ensure that appointments are not missed. However, interventions identified where not necessarily being followed through, for example, one person assessed as a high risk of falls, identified the need for a referral to the Occupational Therapist (OT) to be made, there was no evidence recorded to reflect this referral had been made. Also, where the waterlow assessment score for an individual was recorded as high, there was no information recorded to reflect they had been issued with appropriate pressure reliving equipment. A check of their room whilst touring the building confirmed the person had been provided with this equipment. The AQAA stated that changing needs are documented through a daily recording system. A previous recommendation was made for the daily statement written by staff needed be more informative of the care actually given based on the presenting needs that day. Review of the daily records reflected that there has been an improvement in the recording; these clearly stated the care and support given to individuals. People spoken with and entries in residents care plans identified that people moving into the home are able to retain their own General Practitioner (GP). This is normal practice unless the GP has written to the person stating they were now living outside of the practices catchment area. Where this applies the individual is supported to register with a new GP. Regular visits were documented in people’s care plans showing that people are supported to access their general practitioner (GP) and other local health services relevant to them. Resident’s and relatives surveys reflected that people feel they receive good care. Comments included, “I have received medical care from my own doctor on a number of occasions” and “I am always kept informed about my realtives care and consulted over medical conditions” and “the care we receive is excellent”. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 13 Information provided in the AQAA and verified during the inspection identified that the home has good medication policies and procedures in place. This includes a self-assessment process for residents to administer their own medication to maintain independence. The AQAA also states that controlled drugs are being kept in line with national legislation. The controlled drugs register confirmed that the home currently have four people prescribed controlled drugs. These are locked separately within the medication room. An audit of the control drugs against the register and people’s Medication Administration Record (MAR) charts was found to be accurate. However, concerns were raised with the manager over the large stock of Temazepam held for one resident. The manager assured the inspector these were being collected by the pharmacy later in the day. A senior member of staff was observed administering the breakfast medication. Medication is mostly pre packed by the pharmacy into blister packs. At the front of people’s blister pack is a front sheet with their details. These include a photograph for identification purposes. Records were on the whole good, with the Medication Administration Record (MAR) being consistently completed. Staff spoken with and training records confirmed that staff responsible for administering medication have received up to date medication training. The AQAA stated that the home has policies and procedures in place to instruct staff on the rights of people using the service. This is discussed as part of the staff induction programme to highlight the importance of personal intervention being carried out within the privacy of the individual’s room. Staff were observed treating people with respect and dignity taking their time and concentrating on each individual they were caring for. A thank you card was seen displayed on the notice board thanking staff “for all the kindness and care shown to our relative’s stay with you during the last few weeks of their life, we know they were content and felt safe and happy”. The new care plan format has a section for residents to record their end of life needs. These issues had not yet been discussed and agreed with the individual and their relatives. This information needs to be established to ensure the resident’s wishes are respected about what they want to happen if and when their health deteriorates and where they would wish to cared for at such time. Woodland Manor DS0000060707.V352537.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, 15, People who use the service experience good quality outcomes in this area. People who use this service receive a good standard of fresh and appealing food and are able to live the lifestyle they choose, however, further work is required to ensure social life within the home is organised to suit the needs of all of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA and verified at inspection confirmed that residents are able to exercise choice and control over their lives. Discussions with the people using the service confirmed that they are given the freedom and support, where required, to make decisions about how they spend their time, keeping to their own preferred routines. They described their experience of living in residential care and commented, “I prefer to be alone, I enjoy my own company and doing my own thing” and “this is my home and I am very happy here”. Residents spoke of developing new friends since moving into the home and being able to maintain family relationships, emphasising visitors are welcome at any time. Entries in the visitor’s book confirmed that friends, relatives and family visit on a regular basis. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 15 Preparations were in process for a resident’s 100th birthday celebration, which had been arranged jointly by the resident’s family and the home. The dining room had been decorated with bunting and balloons and a special birthday cake had been purchased for the occasion. Family, friends and residents were seen enjoying the party. The individual and their relative spoken with could not praise the home enough for the party and the excellent care and support provided by the staff. A previous requirement was made for activities to be available, flexible and varied to suit service users’ expectations, preferences and capacities. Information provided by the activities co-ordinator confirmed that there has been an improvement to the level of group and individual activities provided. However, feedback obtained through residents and relatives ‘Have your Say’ surveys and discussions with people living in the home gave a mixed response to the level of activities arranged by the home. Comments included “I have been impressed by the level of entertainment and activities arranged by the home” and “we have an extremely efficient, activities co-ordinator, who seems to meet all various needs”. Alternatively, comments suggested, “more activities and walks in the fresh air, entertainment and outings would benefit residents to keep their minds active” and “it would be nice to do an activity every day, rather than the occasional, after being active looking after a home, it can be boring sitting in front of a television”. Time was spent with a small group of residents sitting in the lounge, watching the television. They were watching the morning chat show, hosted by Jeremy Kyle. A resident commented, “I like watching this programme as it keeps me informed of what is happening on the outside”. They also spoke of taking part in other activities, most recently a visit to Stoneham Barns. Another person commented,” I don’t get fed up ever”. Other residents were engaged in knitting, reading the daily papers and chatting over morning coffee. The activities co-ordinator has designated days for activities, which equate to five days over a two-week rota. Where previously they were expected to help out on care at times of staff shortages, recent recruitment has improved staffing levels, allowing more time for scheduled group activities and one to one time with individuals. Information provided in the AQAA and discussed with the manager confirmed they are currently looking to increase the activity co-ordinator hours. They are also looking at further training to change the culture of staff to break away from the focus of group activity to more focused individual activity. More fund raising events have led to extra money available in the ‘residents amenities fund’ to pay for entertainers and outings of residents’ choice. Records examined reflect the activities co-ordinator has worked hard to improving activities within the home. An activity diary reflects the range of Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 16 activities that have taken place and those planned for the future. These included trips out, a fish and chip supper and a cheese and wine evening. The home has become a member of the National Association for Providers of Activities for Older People (NAPA). They receive a quarterly brochure, suggesting ideas for activities within the home that are age appropriate, for example, a Beaujolais evening, National Poetry day and a celebration of All Hallows. People living in the home are encouraged and supported to maintain links with the local community. For residents who choose to attend, ladies from the Whitton Church, visit the home for prayers and bible readings. A number of people choose to attend the local church and are escorted there and back by members of the congregation. The local library hold a coffee morning on a regular basis, transport is provided for residents who choose to attend. Time was spent talking with the chef who demonstrated a good understanding of the needs of the people living in the home and the importance of good food hygiene. Breakfast and lunchtime meals were observed. Tables in the dining room were nicely laid with tablecloths. The midday meal consisted of a variety of choices, which looked appetising and were nicely presented. People spoke highly of the food, comments included “food is excellent” and “all meals are very well cooked and varied, I have one or two special needs, but each day these are always covered” and “the meals are so tasty, I always look forward to each meal”. Woodland Manor DS0000060707.V352537.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, People who use the service experience good quality outcomes in this area. People using this service are able to express their concerns and have access to a robust and effective complaints procedure and are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA and verified at the inspection confirmed that Woodland Manor has a robust complaints procedure in place, which is documented in the statement of purpose and service users guide. Additionally, a copy of the complaints procedure was seen on the notice board and leaflets called complaints, concerns and compliments were on display in the entrance hall. The AQAA states that complaints and feedback is actively welcomed and used to improve the service. Discussions with people living in the home, confirmed they would raise any concerns with the manager as they occurred. This was supported by comments made in residents and relatives surveys, for example, “I have not had to make a complaint, staff have always acted when I have raised specific issues around my relatives care” and “this never seems to arise in my case, but if I was unhappy about something I would speak to the manager or a carer”. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 18 The complaints’ log was seen and showed that the last complaint entry was made in September 2006. The complaint had been investigated, and the findings fed back to the complainant who was satisfied with the outcome. Neither the home nor the Commission have received any further complaints about this home. The home’s adult protection policy is in line with the Department of Health (DH) guidance ‘No Secrets’ and Suffolk County Council procedure. However, this procedure was disbanded in February this year and the Adult Safeguarding Board (ASB) created in its place. This was discussed at the inspection and the need for the procedure to be updated to reflect this change. Information taken form the AQAA reflects Anchor have appointed a specific person to support a consistent approach to adult protection. This person will monitor adult protection issues and identify where themes may occur. The home operates a thorough recruitment policy, which ensures all appropriate checks are obtained prior to new staff commencing employment. Staff personnel files seen at the time of the inspection, confirmed that all newly employed staff are subject to Criminal Records Bureau (CRB) and Protection Of Vulnerable Adults (POVA) checks. To further safeguard people living in the home records confirmed that all staff had attended training to recognise abuse in the home. Staff spoken with demonstrated a good understanding of what constituted as abusive practice and would have no problem reporting an incident or an individual if they had any concerns about their conduct. Discussion with the administrator confirmed that people living in the home are encouraged to manage their own personal finances, however where they are unable to relatives and /or another suitable person is encouraged to manage their financial affairs on their behalf. Where no suitable person is able to support the individual, Anchor will become involved in managing their personal monies. A formal assessment is completed, but the resident will remain in control and be fully consulted regarding expenditure. Anchor have their own accounting system, SMART. Each person has a Residents Personal Monies account (RPM), which is managed by the administrator. A database provides an audit trail of expenditure where money is withdrawn and a record of their personal allowance is paid in. All transactions require two staff signatures. Woodland Manor DS0000060707.V352537.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, 20, 21, 22, 24, 25, 26, People who use the service experience good quality outcomes in this area. People can expect to live in a home that is homely, comfortable and decorated to a good standard, which has an ongoing plan of upgrade in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQQA and verified at the inspection confirmed that the home is situated in a quiet area with views of large well-kept grounds and countryside. However, the driveway approaching the home has a number of potholes and is uneven. A relative’s survey commented about the driveway, stating, “I have often seen residents walking on this road and to me it looks dangerous”. The home has previously been found to offer accommodation to a good standard, therefore a brief tour of the environment was made. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 20 Furnishings and lighting throughout the home are domestic in character and of good quality. Flowers and bowls of fruit were seen placed around the home, creating a comfortable and homely atmosphere. A resident’s ‘Have Your Say’ comment card stated, “It is a pleasure to invite visitors at anytime to the home, it is clean” and “the home is always spotless, and always smells fresh”. Information provided in the AQAA and confirmed during the inspection identified that all people living in the home have their own room with specific equipment assessed to meet their individual needs. Appropriate aids for safe moving and handling were sited around the building and people had been provided with aids and equipment for the prevention of pressure areas, where required. In order to create level access the home has a shaft lift in place. There are adequate number of communal assisted bathrooms, showers and toilet facilities to meet people’s needs. It was noted and discussed with the manager that one of the bathrooms with a walk in shower required repairs to tiles that had cracked. Bathrooms and toilets are fitted with grab rails, to help people maintain their independence. All rooms seen were fitted with a call bell. Observation throughout the day confirmed that staff responded promptly to the call bells. Peoples’ rooms are nicely furnished, reflecting their individual personalities and interests. Two rooms have the addition of a kitchenette and an en-suite. All doors are lockable, which promote privacy, although staff do have an override key in the case of emergencies. People moving into the home are able to bring small items of furniture as well as other items such as ornaments, pictures and photographs. Lockable storage space is provided for small items of value. There is an ongoing programme of decoration and refurbishment of the home. To date, refurbishment has taken place to the lounge, dining room, entrance and some service users rooms. Further work is scheduled to refurbish the kitchen and to replace the emergency lighting and the nurse call system. Discussion with the manager confirmed that the previous plans to relocate the laundry are on hold. A previous requirement was made for the laundry room to have a washable floor that is sealed to prevent any potential infections being spread. The carpet has been removed. The manager confirmed quotes have been obtained to find the most suitable flooring to be laid, in respect of cost and durability. The original parts of the home need to be part of the planned refurbishment to provide the same standard of accommodation and décor as the newer extended parts of the home. Cleanliness was very good throughout the home. Appropriate hand-washing facilities of liquid soap and paper towels are situated in all bathrooms and toilets where staff provide assistance with personal care. Random testing of water temperatures reflected that the water supply is within the recommended 43 degrees centigrade, which minimises the risk of people living in the home scolding themselves when taking a bath or shower. Woodland Manor DS0000060707.V352537.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, People who use the service experience good quality outcomes in this area. The home has an established staff team, available in sufficient numbers who have the skills and experince to meet the specific needs of the people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA identified staffing numbers are appropriate to the size of the home and the needs of the residents. The home is staffed by a team leader on each of the three shifts, with four care staff in the morning, three in the afternoon and two at night. In addition there are a team of domestic staff, catering staff and a maintenance person. Staffing levels were discussed with the manager as a result of comments received from residents and relatives. Nine residents ‘Have your Say’; surveys were positive that staff are available to help them, however comments included, ‘may have to wait due to not enough staff’ and ‘staff are sometimes a long time answering the bell’. Two staff surveys commented ‘sometimes we are short staffed due to staff sickness’ can be very hard work for those working at the time. The home has a history of using agency staff, which ensures that there is sufficient staff on duty. However, a relatives Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 22 comment card raised concerns that agency staff do not know individual residents and their needs. The manager explained that they have recently recruited new staff and is reducing the amount of agency staff used. They have recruited staff over and above previous staffing levels, which means they have one extra staff above the normal roster to take into account holidays and staff sickness. The duty roster for the week commencing 24th September reflected that agency staff was only covering three shifts. Staff spoken with confirmed that generally staffing levels are good. The home has a robust recruitment process. Staff files are well organised and contain all the relevant documents and recruitment checks, including a Criminal Records Bureau (CRB) check and a Protection of Vulnerable Adults (POVA) check. Staff had also been issued with a job description and the terms and conditions of employment. Residents and relatives’ surveys were complimentary about the staff and were confident that they met their needs. Comments included, “staff are very helpful, they are available day and night” and “the staff are very hard working and friendly, the atmosphere in the home is lovely”. Woodland Manor has a history of good access to training. This was confirmed in discussion with staff and from information provided in the staff ‘Have your Say’ comment cards. Staff confirmed they receive good training, which is relevant to their role and which helps them to understand and meet the needs of the people using the service. Training records confirmed staff had received training for back care, involving moving and handling, basic health and safety, protection of vulnerable adults, fire safety, infection control and food hygiene. Team leaders have attended Boots safe administration of medication training and most recently training to implement the new care plans. The team leaders are to cascade this training to all care staff. Other training has taken place to meet the specific needs of people living in the home. The district nurse provided a session about diabetes. Staff have also attended dementia awareness training. Although the home are not registered to provide dementia care, two people living at the home have developed the condition. Additionally the home is in the process of liaising with the speech and language department at the local hospital to help support the communication needs of people whom have had stroke. Staff spoken with confirmed that Anchor is a good company to work for as they provide good training, which enables them to develop their roles. A team leader has attended train the trainer course and holds the responsibility as the back care trainer. All new staff are required to complete induction training. Anchor has designed their own induction pack, in line with the National Training Organisation (NTO), Skills for Care induction. Figures taken from the AQAA reflect the home employs 27 full and part time care staff. 5 staff currently hold NVQ at level 2 Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 23 or above, with 5 staff in the process of completing an NVQ. The service does not currently meet the required standard of 50 of staff to hold a recognised qualification. Woodland Manor DS0000060707.V352537.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, 32, 33, 34, 35, 36, 37, 38, People who use the service experience good quality outcomes in this area. People using this service benefit from the leadership and management approach of the home, which is based on openness and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA and verified at the inspection confirmed the Registered Manager is qualified and experienced in the running of a home. They have completed the Registerd Managers Award (RMA), Diploma in the Management of Care Services and a National Vocational Qualification Assessors Award. Although the manager is in day to day control there are clear lines of accountability and delegation of duties within the whole staff group. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 25 Discussion with staff confirmed they find the manager approachable, friendly and supportive. Residents, relatives and staff comment cards, provided good feedback about the manager and the management of the home. Comments included, “everything is well done and appreciated” and “I receive very satisfactory care at this home” and “The home is run very well; residents are treated with dignity and privacy at all times”. A previous recommendation was made for the quality assurance systems within the home to be more widely understood by staff and should include monitoring quality of care plans. Anchor has developed questionnaires for residents and relatives to complete to obtain feedback on the quality of service they receive. These are in the process of being distributed. Following analysis of the surveys, the outcomes will need to be published and a copy forwarded to the Commission for Social Care Inspection (CSCI). The manager advised that to ensure people living in the home have a say in how the service is managed, the home has regular residents and relatives meetings. They also provided a copy of a record of informal resident interviews, which was conducted in September 2006. Feedback was mostly positive, in particular comments about the food, however a common theme with residents was that they would prefer more and appropriate activities/entertainment. Anchor has systems in place that encourage people to manage their own financial affairs, however where they are unable to do this the administrator helps support individuals to manage their personal finances. A database provides an audit trail of expenditure. This is explained in more detail in the complaints and protection section of this report. A copy of the home’s operating procedure was viewed in the administrator’s office. This sets out the objectives for the financial year 2007 – 2008 and indicates that the organisation continues to be financially viable. Key objectives are for the home to eradicate the use of agency, reach and maintain 97 occupancy, implement new care plans and achieve 75 of staff to achieve an NVQ. The manager produced files with records of staff supervision. These are kept locked in the administrator’s office. Examination of the file identified that regular supervision takes place. All staff are in the process of completing a performance and development appraisal. The home takes steps to safeguard the health, safety and welfare of people living and working in the home. The most recent Gas and Electrical Safety Certificates were seen. Records showed that equipment is regularly checked and serviced. The building complies with enviromental health standards and the local Fire service requirements. The Fire alarm system is serviced on a regular basis and the fire logbook confirmed that regular training and drills take place. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 26 Examination of the incident and accidents file identified there a high number of falls being recorded. The manager advised that they have been in contact with a falls assessor. Equipment, such as pressure mats have been provided to alert staff when residents are moving around in their rooms to help minimise the number of falls. The activities co-ordinator arranged for a company to visit the home who provided a talk to residents and staff about falls awareness, the importance of good diet and exercise. They also promoted products available for people to use to minimise risk of injury from falls. The activities coordinator is looking to develop regular armchair exercise sessions. A lot of information about the home and policies and procedures still refer to ‘Golden Days’, these should be updated to reflect ownership by Anchor Trust. Time was spent with the chefs’, who demonstrated a good understanding of the needs of the people living in the home, the importance of good food hygiene and health and safety. All foods were being stored in accordance with food safety standards. Documentation was produced to show that the required temperature checks for fridges, freezers and food delivered to the home are being kept. They are well qualified and described feeling supported by the manager and Anchor’s catering support manager who visited once a month to audit practices in place in the kitchen. Woodland Manor DS0000060707.V352537.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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 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 3 2 3 3 3 X 3 3 2 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 3 3 3 3 3 2 3 Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15(1) Requirement A timescale for the implementation of the new care plans must be set and implemented. This will ensure that each resident has a care plan that reflects their needs. (This is a repeat requirement from 03/10/06 and 06/02/07) Service users care plans must be accurate and kept up to date. This will ensure that the care plans reflect the individuals assessed and changing needs. (This is a repeat requirement from 08/12/05 and 03/10/06 and 06/02/07) Where risk assessments identify an individual is at risk, interventions must take place. This will ensure that appropriate action is taken promote the individuals health and welfare. For example, a person assessed as a high risk of falls, identified the need for a referral to the Occupational Therapist (OT) to be made, there was no evidence recorded to reflect this referral had been made. DS0000060707.V352537.R01.S.doc Timescale for action 01/11/07 2. OP7 15(2)(b) 01/11/07 3. OP8 12 (1-3) 01/11/07 Woodland Manor Version 5.2 Page 29 4. OP9 13 (2) 5. OP19 13 4 (a) 6. OP26 13 (3) There must be systems in place 01/10/07 for tighter monitoring the amount of controlled medication held at the home. This will ensure there is an effective audit trail of medication and will ensure the safety of the people living in the home. As part of the planned 30/11/07 programme of maintenance the driveway approaching the home requires repair or resurfacing. This will make it safe for people living in the home to use. The laundry floor should have an 30/11/07 impermeable finish and be readily cleanable. The will ensure the premises are kept clean and hygienic with systems are in place to control the spread of infection. (This is a repeat requirement from 06/02/07) 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. Refer to Standard OP11 Good Practice Recommendations The end of life needs of people living in the home need to be discussed. This will ensure that in these circumstances the individual and their relatives will be treated with dignity and respect and in accordance with their wishes. Further work is required to ensure that the social life within the home is organised to suit the needs of all of the residents. To ensure people using the service are in safe hands a minimum of 50 of care staff should hold a recognised qualification such as National Vocational Qualification (NVQ). 2. 3. OP12 OP28 Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 30 4. OP37 Information about the home, including policies and procedures should to be updated to reflect ownership of the home. Woodland Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Manor DS0000060707.V352537.R01.S.doc Version 5.2 Page 32 - 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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