Inspection on 06/08/08 for Woodland Manor

This inspection was carried out on 6th August 2008.

CSCI found this care home to be providing an Adequate service.

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 Manor 25/09/07

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 09/11/2008.

CARE HOMES FOR OLDER PEOPLE Woodland Manor Whitton Park Thurleston Lane Ipswich Suffolk IP1 6TJ Lead Inspector Pauline Dean Unannounced Inspection 6th August 2008 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.V369848.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.V369848.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.V369848.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) 25th September 2007 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 £355.00 to £630.00 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. Hairdressing, chiropody, toiletries and newspapers are all not covered in the fees and are all charged at cost. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection of Woodland Manor took place on 6th August 2008 over a ten-hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last key inspection in November 2007. At the site inspection, records and documents were inspected and we spoke to the registered manager, care staff and the people living at the home. In addition the Annual Quality Assurance Assessment (AQAA) completed in May 2008 was considered as part of the inspection process and a tour of the premises was completed. Surveys were sent to the home prior to the inspection. Seven surveys were completed by the people living at the home and three staff surveys were completed and returned to the Commission prior to writing this report. Their comments are reflected in this report. During the inspection five people who live at the care home, two carers, catering staff and a relative were spoken with. What the service does well: Woodland Manor was clean, bright and welcoming on the day of the inspection. Overall, ongoing decoration and refurbishment ensure that the property is maintained to a good standard. There was a relaxed and homely atmosphere in the home with an established staff group and during the visit staff were seen to interact well with the residents. Admission processes in the home were managed well, with care planning and record keeping for the people living at the home in good order. Consideration has been given to all aspects of health, personal and social care needs with consideration given to the resident’s wishes. People living in the home spoke of being able to make choices around what they wished to eat, what they wished to do and where they liked to spend their time. Three people spoken to at the inspection said that they enjoyed the Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 6 leisure activities on offer; one person said they were able to choose whether to go or not and sometimes they liked to look in on from the side. Other positive comments are reflected in the body of this report. 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 Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Woodland Manor DS0000060707.V369848.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.V369848.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): 3 & 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who come to live at the home can be confident that their needs will be fully assessed and these will be met. EVIDENCE: At the inspection visit, the files and paperwork for three people living at the care home were sampled and inspected and we were able to speak to all three residents. The pre-admission paperwork for two people who had moved into the home since the last inspection was sampled and inspected. This had a completed pre-admission assessment and a care manager assessment, which had been completed by the registered manager and/or the registered manager and a team leader. The registered manager said that they prefer to complete Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 10 an assessment with a colleague to give an opportunity for referral and consultation. These assessments are completed prior to admission to Woodland Manor and one had been completed in hospital and the other in the prospective resident’s home. Both of these assessments were detailed and comprehensive and gave a basis on which to create a care plan. Within the Annual Quality Assurance Assessment (AQAA) there was confirmation of the admission process as detailed above. It was said that the ‘knowledge and skills of the staff group are appropriate to service user need.’ This was evident from the use of a detailed format which highlighted individual needs of prospective residents. All seven surveys completed and returned by people living at Woodland Manor said that they had received enough information about the home before moving in so that they could decide if the home was the right place for them. Within these surveys it was said ‘We had an excellent tour of the home and everything was explained. My mother was also given a good introduction and allowed to spend time at the home before accepting a place.’ Another resident said ‘I was recommended this home.’ Five out of the seven said that they had received a contract, two said they had not got a contract. A relative spoken to at the inspection said they and their family had been involved in moving their relative into the home and they had found this had been managed very well. Woodland Manor does not offer intermediate care. Woodland Manor DS0000060707.V369848.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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can be assured that their care needs will be met through their individual plan of care. They cannot always be assured that they will be safeguarded by the home’s medication practices and procedures. EVIDENCE: The care plans for three people living at the care home were sampled and inspected. Two of these residents had been admitted to the home since the last inspection. On each file there was a photograph of the individual and information had been gathered under the heading – ‘Life History.’ The care plan was divided into four sections covering personal hygiene, mobility, activities and medication. Within each of the care planning objectives care had Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 12 been taken to include the resident, for each section had a heading which asked and detailed what the resident wished and could do for themselves and what they needed assistance with. The action, which needed to be taken by carers was graded as needing assistance, support and encouragement and in all three care plans there were good examples of care needs with the expected outcome. Within a care need relating to mobility consideration had been given to the task, the manoeuvre needed, the equipment needed and the number of carers required. The care needs covered this way were with regard to bathing, lifting and picking someone up from the floor. Social activities were considered within each individual care plan. A list of activities was included on each file and the carer was informed of the resident’s request regarding joining group activities organised by the home. On one file it was said that the resident would inform the home if they wished to join in the group activities, with the staff actively promoting what activities were going on. Evidence was seen of regular monthly reviews of care plans. One entry seen detailed a slight change to the mobility of the resident in the morning. They were recorded as using their wheelchair to come to breakfast. This was discussed with the registered manager and it was acknowledged that these changes need to be detailed in the individual’s care plan. It was recorded on the ‘Alert Form’ which is good way of alerting staff to changes in the individual’s daily life, health and social visits and needs. These alert sheets were found in the front of each care plan section. However, in this situation there is a need for this to be transferred into the care plan of the individual. The management of medication was also considered with the resident’s care plan. One person case tracked was diabetic. Their care plan covered this aspect of their care well. This was confirmed by the resident who said that they were able to manage their insulin injections and blood monitoring testing. They said that they felt supported and enable to be independent in this aspect of their care. Four out of the seven completed surveys completed by residents said that they ‘always’ received the care and support they needed. One relative had commented that their relative had been unwell recently and they had ‘been receiving extra care, which has been excellent.’ Three residents said that they ‘usually’ received the care and support they needed with a relative commenting that they sometimes felt that there was not enough staff at the weekends. They did say however, that ‘Staff are always helpful, cheerful and kind.’ Within the care plan files sampled records were seen of visits to the home of GPs, chiropodists, hospital appointments and visits by District Nurses. Records Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 13 were available and in use for assessing and recording pressure sores and the management of nutritional needs and continence. At the inspection there was evidence of aids and equipment to aid mobility, prevent pressure sores and ensure continued independence. Four residents had stated in the Commission‘s survey work that they ‘always’ received the medical support they needed, two said they ‘usually’ received the medical support they needed and one said they ‘sometimes’ received the medical support they needed. Within the AQAA it was stated that the home has a ‘Referral system in place to ensure access to other health and social care professionals’. From speaking to the manager and residents it was evident that appropriate referrals are sought following medical advice. It was also stated in the AQAA that health care visits and appointment are noted in the blue section of the care plan, thus ensuring that appointments are not missed. Since the last inspection there have been three Regulation 37 notifications relating to the administration of medication and record keeping. In each situation the home had notified the Commission for Social Care Inspection (CSCI) and other authorities e.g. the Police as appropriate. They had taken immediate action to safeguard the welfare of the resident and they had carried out an investigation. In each case human error had contributed to these shortfalls. Medication administration, storage and record keeping was sampled and inspected at the inspection visit. The registered manager took us through the processes for the ordering and returning of medicines and they detailed the practice and procedures for ordering, receiving, recording and administering medication. A team leader is responsible for checking in all medication as it is received. All three residents used in the case tracking at this inspection were on medication and their medication and records were inspected. The home is using a Monitored Dosage System (MDS). Medication is held in two medication trolleys, which are securely fixed to a wall. Further medication is stored in a locked roll-top cabinet, located in the same area. Medication record keeping was accurate and in good order for two of the resident’s sampled. Controlled drugs are held in a Controlled Drug cabinet and are administered through a Controlled Drug register. One of the resident’s sampled was receiving a Controlled Drug and this was in good order with all entries countered signed as administered. This ensures that residents are safeguarded from poor medication procedures, as there is an ongoing monitoring and auditing process. An error was found in the blister pack records for one resident. There was a discrepancy in the labelling found on the morning blister pack. Instead of detailing this medication as being prescribed 4 times a day the entry was 3 Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 14 times a day. The quantity of tablets however was correct for administration 4 times a day and the Medication Administration Records (MAR) were correct. Following this inspection the registered manager wrote to us and informed us that there had been an increase from 3 times a day to 4 times a day. This had been the resident’s GPs instruction. The registered manager said that the home is looking to Boots for a Foundation Course in medication and they are looking for external competency testing by another home’s manager. This is with regard to ensuring the safety of residents following the recent Regulation 37 notifications relating to the administration of medication and record keeping. As stated earlier in this report one of the resident’s sampled self- administered their insulin and they conducted the blood glucose monitoring. Records seen detailed this and policies are in place around self-medicating. During the inspection staff were seen to retreat people with respect and to promote privacy as the entered their bedrooms. They were seen to knock at the bedroom door and wait until the resident said they might come in. During the day we saw staff approach and speak with residents in a professional manner, chatting and joking with them as they assisted the resident. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service People who live at the home can expect to be given choices about how they spend their time, visiting arrangements and meals. EVIDENCE: At this inspection we met the Activities Co-ordinator who said that they were able to speak with new residents as they move into the home to find out what they like to do and to invite them to join in with the planned group activities as they wished. The Activities Co-ordinator said that they work four days a week operating as a carer and planning and arranging activities. They were able to evidence through their records the variety of outings, activities and entertainment they have brought into the home. Bookings were seen for musicians, singers, a pantomime, church services and the Salvation Army. They were clearly enthusiastic about this aspect of their work and they said that they encouraged Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 16 staff, families and residents to be involved. They said that they were supported in this work by the manager, all staff, residents and families. An example of this was a recent BBQ, which had been enjoyed by all. The event had gone very well with residents inviting their relatives to attend. This was confirmed by three residents who said they had had a good time and they had enjoyed the food. Outings and trips out are arranged. One visit to Felixstowe had already taken place and a second was planned. A coach trip had been arranged for Bury Gardens and one resident spoken too said that they had really enjoyed this trip. Another resident spoken to said that they are supported by the home and they were able to attend church regularly. Furthermore as well as the regular church services in the home they told us of a recent service in the home, which had focussed on remembering family and friends who had died. They said that they found this service thought provoking and they had been able to enter the name of a loved one in the newly created Book of Remembrance. This book was seen at the inspection. A second resident also confirmed that they thought it was a good idea and they said they had been able to participate in the service and make an entry into the Book of Remembrance. They understood that another service was to be arranged in the future. The registered manager and the deputy manager said that visitors are welcome at any time. They said that visitors are welcome to see residents in their room, in the small dining room or the main lounge areas. All three residents spoken with said that they were able to receive visitors as they wished. One person said that refreshments were offered and another person said that they were taken out for a meal by their relatives. A relative visiting Woodland Manor on the day of the inspection confirmed that they were always made very welcome and they found both staff and management approachable should they need to speak with them. Records were seen on care planning files of the property residents brought into the home. Evidence was seen of this as we went around the home. Residents had pieces of furniture, ornaments, pictures, photographs, books, televisions and radios in their rooms. The registered manager said that the people living at Woodland Manor are encouraged and supported to manage their personal money as they are able. At this inspection we spoke with a member of the catering staff of the home. They told us that residents have two identified choices each lunchtime. There is a 4-week rotation menu in the home, which details the food to be served at Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 17 breakfast, lunch and teatime. Whilst the home has a comment book for comments relating to catering, no records are kept in the home of the meals taken by each resident. This was raised with the manager who acknowledged that without these nutritional records the home was unable to evidence that residents have a varied, wholesome and nutritious diet. Comments seen in the catering comment book were positive. At the recent BBQ the food was said to be excellent and good and the ‘carers were very helpful’. Records were seen of temperature checks completed on the two fridges and two freezers, which held food for residents. Some of the most recent entries were found to be high. When this was raised with the registered manager it was realised that the probe was malfunctioning. This was corrected and temperatures were taken later in the day which were within acceptable parameters. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 18 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can expect their concerns to be taken seriously by the care home. EVIDENCE: Woodland Manor has a complaints procedure. On the day of the inspection this did prove difficult to find. The registered manager said this was because the home was reviewing and revising some policies and procedures, including the Service Users’ Guide which had a copy of the procedure. Following the inspection a copy of the complaints procedure as developed by Anchor Trust was sent to us. This document had been approved in January 2008 and a review date was set for January 2010. The complaints procedure sent to the Commission detailed the principles and standards adopted by Anchor Homes and it outlined the three stages of a complaint referral. Detail of how complaints are investigated and any action taken as a result of the complaint was noted in this document. Reference to the Commission for Social Care Inspection (CSCI) was made in this procedure. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 19 This was with regard to complaints received by the Commission about the service. Within this it stated – ‘An external Agency like CSCI or the Local Authority Social Services Department is empowered to undertake investigations and take appropriate action if Anchor has not met its obligations to any resident’. It should be understood that the Commission will not investigate complaints, but will review the management of complaint investigations through inspection and regulation. At the inspection we saw the complaints log and evidence was seen of two complaints received this year. Both were clearly detailed, with records detailing the investigation and the action taken. These clearly audited that action taken and considered if further action was required in the future. This evidenced that residents are safeguarded and that their views are listened to and considered. Woodland Manor has a Whistle-blowing policy. This too was sent to the Commission and detailed it’s aims, the background history and legislation and the ways a member of staff can raise a concern. Detail was given of how a concern would be investigated and how the outcome would be shared with the complainant. Details of independent help and advice were also noted in this document. At this inspection a carer told us that they had raised concerns under Whistleblowing. This was ongoing and senior management were involved in these discussions. This was later confirmed by the registered manager and should there be any further action required e.g. a Safeguarding Alert referral then the Commission would be informed. As with the complaints procedure, the registered manager was unable to locate the current adult protection procedure. The most recent document found was dated July 2004. However, following the inspection a copy of the ‘Safeguarding of Vulnerable Adults’ policy was sent to the Commission. This had been approved in July 2007 and was set for review in May 2009. As with the complaints procedure, we would have expected that a paper copy of the document would have been readily available in the home to ensure that all staff have the opportunity to read and access this document should they need to at any time. This would therefore further ensure that residents are safeguarded, for carers would have the knowledge and confidence to raise concerns as detailed in the policy. Following this inspection we have been informed that copies of these policies and procedure are to be found in the Quality Manual to be found in the staff room and the main reception area. The ‘Safeguarding of Vulnerable Adults’ policy is an informative document detailing the different types of abuse, safeguarding procedures linked to recruitment and checks, the investigation processes and action to be taken Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 20 and collaboration envisaged when working with other authorities such as the Police, the Commission and local Safeguarding Units. Reference was made for the need for staff to be trained. It was stated that a one-day training on safeguarding was required for care staff and these would need to be regularly updated. In addition all support staff would be expected to attend Awareness Training, which would be run annually. Training records showed that twelve staff had attended and completed safeguarding training this year and all three staff members who had completed the Commission ‘s surveys said that they did know what to do should a resident, relative, advocate or friend raise a concern about the home. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 21 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Woodland Manor have homely, comfortable and safe surroundings, which are kept clean and tidy. EVIDENCE: A tour of the premises was conducted at the inspection. All of the communal areas and some private bedrooms were seen. Overall, Woodland Manor was light, bright and clean. Within the AQAA it was stated that there had been some refurbishment of the lounge, dining, communal areas and resident’s bedrooms. This was noted in the lounge/conservatory area although it was not evident in the small dining/meeting room. Bearing in mind that this room was used by residents and their visitors it was not very welcoming. Wallpaper Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 22 and the wallpaper frieze was torn and marked and the furniture in this room was a mixture of furniture brought from other areas of the home. This was particularly evident in the dining chairs seen in this room. Some were high and some were low, some having a cushion to raise the person sitting at the table. This was discussed with the registered manager and it was acknowledged that it did give a poor impression to visitors and relatives who were likely to use this room. There was evidence of this room being used as a staff lounge/meeting room with filing cabinets and shelves with administration paperwork available. This was raised with the registered manager and with some re-organisation and decoration this room could be more inviting and resident friendly. Drink making facilities are also located in this room and this too could be beneficial when visitors are in the home. The registered manager confirmed as stated in the AQAA that some new carpeting had been fitted on some landings with more new carpet to be fitted on the staircase. They said that both the emergency lighting system and the call bell system are to be replaced within the April 2008 budget. They did not have dates for this work. The external decoration and maintenance of the grounds and driveway is ongoing. Some repairs have been made to the shared private driveway and consideration is being given to providing an alternative pathway into the home’s grounds from the existing driveway. Woodland Manor is located in large grounds with lawns, trees and shrubs surrounding it. It is located in a rural setting, which was remarked upon by one resident spoken to who said that they ‘loved the view’ from their room and they like the quietness of the location. Immediately from the main lounge/conservatory there is a large paved patio area, which is easily accessed from this room. On the day of the inspection three residents were sitting out in the sunshine and all three said that they enjoyed sitting outside when the weather allowed. The patio perimeter was outlined by pots of flowers and shrubs. These were bright and appreciated by the residents. One resident said that they had been involved in potting up these containers. Since the last inspection the home has had a visit from the environmental health department. They had visited the home and conducted an inspection under the Food Safety Act 1990 and Regulations. As a result some requirements had been made on the home. These were with regard to cleanliness of the kitchen area, the monitoring of food, fridge and freezer temperatures, the washing of hands and Basic Food Hygiene training requirements. The registered manager said that they believe they have complied with all of these requirements and they await a second visit by the Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 23 environmental health department to confirm this. They said that they are still waiting for the refurbishment of the kitchen as had been planned by Anchor Homes. They said that this was on hold. At this inspection we were able to speak with the person who works in the laundry. They said that work in the laundry four days a week for twenty hours. When they are not on duty laundry is completed by carers during the day and night. The flooring in the main areas of the laundry were the washers and dryers are located has been re-surfaced and sealed with floor paint. Other rooms in this cellar which house linen and ironing facilities are still carpeted as are the corridors in this area. These carpets were worn, solid and generally in poor condition. When raised with the registered manager, this was acknowledged and consideration is to be given to removing the remaining carpet. We were told that some thought had been given to relocating the laundry, but as this was not looking to be imminent and the refurbishment of the laundry is overdue. Laundry services were said by two residents to be ‘good’. One person said that they could change their bed one day and the bed linen would be laundered and returned iron that same day. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 24 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. This judgement has been made using available evidence including a visit to this service. People who live at the home can expect to be supported by sufficient staff with skills and knowledge to meet their needs. They can be assured that appropriate recruitment practice has been followed to safeguard their welfare. EVIDENCE: The registered manager said that staffing levels are calculated according to residents’ needs. Currently there are four to five carers on duty each morning and four carers on duty in the afternoon. Included in this number are a team leader on each shift. Four carers remain on duty until 21.30 hours when two awake night carers and a team leader come on duty until the morning. In addition to the care staff, the registered manager or the deputy manager are on duty. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 25 The home has a laundry person, gardener/maintenance person and three housekeepers. The registered manager said that these levels of staff ensure that residents’ needs are met and there is some flexibility in staffing hours to meet unplanned for events when more staff are needed. Within the survey work conducted by the Commission, one staff member said that ‘usually’ there is enough staff to meet residents’ individual needs and two staff members said that there was ‘sometimes enough staff to meet residents’ individual needs. Four residents said that there was ‘always’ staff available when they needed them and three said there were ‘usually’ staff available when they needed them. The registered manager said that National Vocational Qualification (NVQ) was ongoing. Two more staff have completed a NVQ Level 2 in Care qualification and the home now has 33 of their care staff with a NVQ Level 2 or equivalent. Both the deputy manager and a night carer have recently qualified as a NVQ Assessor and we were told that they are awaiting confirmation. Staff recruitment files for two care staff were sampled and inspected. One of these had joined the home in 2007, the other in 2006. Overall these files were in good order with evidence of good staff recruitment practices being followed. Full pre-employment checks and an Enhanced Criminal Record Bureau (CRB) disclosure were seen for each person. The only shortfall noted was on each application form the applicants had given details of their employment history, but they had failed to give full date details, for they had omitted to give the month when they had started and ended their employment. The registered manager agreed to ensure that this information is added to these applications and will ensure that this is completed on future applications. The registered manager said that Anchor Trust provide a variety of basic and specific training courses, with all staff who are responsible for the administration of medication attending Boots medication training. In the last year training records there was evidence of training in Health & Safety, Safeguarding, First Aid and Dying with Dignity, which referenced to dementia care. Within the staff files sampled there was further evidence of evidence of BTEC training and Skills for Care Induction training on each file. All three staff members who had completed the Commission ‘s staff survey said that they did have training relevant to their role and all three said that the training helped them understand the individual needs of the residents. Two out of three said that their training helped them to keep up to date with the new ways of working. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home should be assured of good management with an ongoing quality and monitoring system in place and health and safety systems to ensure that the people living in the home are protected. EVIDENCE: The registered manager is experienced and qualified to take on the role of the manager of this care service. Within the home there is a staff structure with a deputy and team leaders who have their supervisory roles and responsibilities. The registered manager said that Anchor Trust provides internal management Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 27 training courses and events to support them in this role. This was confirmed in the AQAA. Woodland Manor conducts internal audits, which are completed by care specialists in the company. These cover topics such as medication, care planning and workshops on training topics such as Infection Control. In addition the home has conducted a quality assurance and quality monitoring system and questionnaires have been given to residents and their relatives. These questionnaires covered personal care needs, activities and housekeeping arrangements. The registered manager said that feedback from these questionnaires would be acted upon and residents and relatives would be informed of the outcome via a resident’s meeting, individually verbally or by letter. As found at the last inspection Anchor Homes have developed systems to encourage the people living in the home 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. Each person has their own account, which we were told was 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 and records are held of money spent with individual receipts held. Safe working practices are ensured through the promotion of training courses as evidenced earlier in this report. Evidence of risk assessments were seen in care planning files which related to individual needs of the resident around mobility, accessing the garden and moving around the home. Consideration is given to maintaining independence and enabling the resident to do things for themselves. As highlighted earlier in this report, the lack of readily available policies and procedures is seen as a shortfall. Whilst it is acknowledged with time the manager was able to locate the updated policies and procedures held on the company’s website, the home should ensure that these are readily available at all times for staff, residents and other visitors to the home. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 29 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 OP9 Regulation 13 (2) Requirement People living in the home must be assured that there are effective auditing systems in place, which accurately detailed and check all medication in 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. People living in the home must be assured that there are detailed records to evidence that they receive a varied , wholesome and nutritious diet. This will ensure that the home evidences that residents have a choice in the food they are offer and they received a balanced diet. Timescale for action 12/09/08 2. OP15 16(4) 12/09/08 Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 30 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 OP16 OP18 Good Practice Recommendations The home’s current complaint procedure should be readily available at all times. The home’s current adult protection procedure should be readily available at all times. Woodland Manor DS0000060707.V369848.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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