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Inspection on 10/01/07 for Woodland Park Nursing Home

Also see our care home review for Woodland Park Nursing Home for more information

This inspection was carried out on 10th January 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There was a very positive open atmosphere in the home during the inspection. All the residents and their relatives spoken to during the inspection said that the staff team were friendly and helpful; always treating them with respect. The staff observed appeared to have a genuine rapport with the residents they were caring for. The comments received and the residents spoken to indicate they knew who to speak to they had any concerns about their care. They also indicated that they felt staff would deal with this to their satisfaction. The way the care needs of the residents is recorded has improved and now clearly states the action staff should take to address the needs of the residents. The residents confirmed the staff talked to them about the care they needed.

What has improved since the last inspection?

The redecoration and replacement of old furniture has continued since the last inspection. The majority of the worn carpets had been replaced. The appointment of more cleaners has meant that the home overall cleanliness is improved. This is being reflected in the comments received from relatives. All the residents plans viewed during the inspection had been reviewed at least monthly or sooner if the residents needs have changed. A resident who had recently been admitted had a full assessment of needs and care plan in place.

What the care home could do better:

The recruitment of new staff had not ensured all pre-employment checks were completed prior to them starting work. This may mean that residents may be at risk from unsuitable staff if the homes recruitment policies are not followed. Although the repairs and renewals and redecoration of the home environment has continued. Some individual residents rooms have still to be refreshed and redecorated. The ongoing repairs and renewal should continue to ensure that the residents continue to have a pleasant environment live in.Although the home has a variety of equipment for use with the residents to meet their needs, at the time of this inspection one of the hoists that a resident needed had been out of service for three days. This had disadvantaged at least one resident because equipment they needed to assist them to get out of bed wasn`t available.

CARE HOMES FOR OLDER PEOPLE Woodland Park Nursing Home Babbacombe Road Torquay Devon TQ1 3SJ Lead Inspector Rachel Proctor Unannounced Inspection 10th January 2007 10:30 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 Park Nursing Home DS0000028764.V310291.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 Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Park Nursing Home Address Babbacombe Road Torquay Devon TQ1 3SJ 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) 01803 313758 01803 313046 Woodland Healthcare Ltd Phyllis Irene Wilton Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (3), Physical disability (31), Physical disability of places over 65 years of age (31) Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Registered for max OP 3 Registered for max PD 31 Registered for max PD 31 Date of last inspection 16th March 2006 Brief Description of the Service: Woodland Park nursing home is an Edwardian dwelling, established as a nursing home in the Babbacombe area of Torquay. It is located approximately 100 yards from Babbacombe Downs with its excellent views over the bay. There is a small shopping area just a short walking distance away. The original building has been extended is to enable it to accommodate up to 31 resident’s. There are 19 single and 6 double rooms available, some with en suite facilities. The rooms are spread over three levels each being accessed by a centrally located shaft lift. Some rooms have sea views. A stair lift is also present between the ground and mezzanine floor. The home has been further adapted to meet the needs of the physically disabled resident’s it provides nursing care for. Meals are prepared in a hotel type kitchen located in the centre of the home. There are disabled bathing facilities on each level and mobile hoist that can be moved between rooms. The home has car parking to the front and side of the building and a small walled garden area for resident’s to sit in, weather permitting. A Registered Nurse manages the home and Registered Nurses are in charge of each shift, supported by a team of Health Care Assistants. The statements of purpose and service users guide are available in the reception area of the home or on request. The fee levels provided on 10.01.07 were up to £516.07 the actual fee is dependant on the needs of the service user and the room occupied. Additional charges are made for chiropody, hairdressing, newspapers and magazines that the service users request. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 10th of January 2007 between 10 am and 4:30 pm. The inspection included a tour of the home, speaking to the residents and staff. And some documentation was reviewed. The lunchtime meal was shared with the residents. The medication systems and practices were inspected. Three residents had their care followed as part of the inspection. Comment cards were received from two relatives, three residents and staff. Some of the opinions expressed in the comments cards have been represented in the text. What the service does well: What has improved since the last inspection? What they could do better: The recruitment of new staff had not ensured all pre-employment checks were completed prior to them starting work. This may mean that residents may be at risk from unsuitable staff if the homes recruitment policies are not followed. Although the repairs and renewals and redecoration of the home environment has continued. Some individual residents rooms have still to be refreshed and redecorated. The ongoing repairs and renewal should continue to ensure that the residents continue to have a pleasant environment live in. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 6 Although the home has a variety of equipment for use with the residents to meet their needs, at the time of this inspection one of the hoists that a resident needed had been out of service for three days. This had disadvantaged at least one resident because equipment they needed to assist them to get out of bed wasnt available. 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 Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The way the resident’s health and personal care needs are assessed and recorded should ensure that the residents receive the care they need. EVIDENCE: Four residents had their care followed as part of the inspection. The manager confirmed that she completes an initial assessment for all new residents admitted to the home. Copies of completed assessments were available in the four residents care plans seen. The manager also advised that where possible the residents are seen prior to their admission. Copies of discharge assessments from hospital or district nursing teams were also available. Each of the residents whose care was followed had a comprehensive assessment of their care needs completed. This included their health; personal, and social care needs. Risk assessments were an integral part of the care planning process adopted by the home manager. The risk assessments included Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 9 pressure sore risk assessments, nutritional risk assessments and falls risk assessment. The manager confirmed that each of the residents had had their nursing needs assessed by an NHS registered nurse. The home does not offer intermediate care. The residents admitted to the home are admitted for long-term care. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are cared for by a staff team who assess and monitor their health and personal care needs, in a way that respects their dignity and choice. EVIDENCE: The residents whose care was followed had a plan of care developed from their assessment of need. The care plans set out the actions that staff needed to take to ensure that the resident receive the care they need. Risk assessments were completed for individual residents and where risks have been identified the care plan reflected this. Risk assessments included prevention falls. The four residents care plans seen during the inspection had been reviewed monthly or sooner if their care needs changed. The manager advised that where possible the residents are asked to sign the plan of care. The inspector spoke to four residents during the inspection. They advised that staff had discussed their care needs with them and they had been asked about their care and what was important to them. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 11 A registered nurse had completed the care plans and assessments viewed during the inspection. The manager confirmed that registered nurses take responsibility for ensuring that the plan of care is relevant to the residents care needs. One resident whose care was followed was identified as a high risk of developing pressure sores. This resident had a specialist airflow pressure relief mattress fitted to their bed. They also had a pressure relief cushion fitted to their wheelchair. The pressure sore risk assessment had been reviewed monthly by the staff. The involvement of the tissue viability nurse specialist was also recorded. The recommendations made had been incorporated into the resident’s plan of care. Continence assessments are completed for residents to ensure they receive the aids equipment they require to promote continents. The bathrooms and toilets have been adapted to enable those residents who are able to use the toilets with minimal support. Supplies of continents pads were available for those residents identified as requiring them. A physiotherapist continues to be employed to provide support for the residents. The physiotherapist had recorded their assessments and recommendations in one of the residents care plans viewed, who had received the support. One of the residents told the inspector that the physiotherapist was helping them to improve their mobility and had given them exercises to do. A nutritional assessment is completed for the residents as part of the risk assessment process adopted by the manager. The assessments seen in four residents care plans had been reviewed monthly. A system for recording the resident’s dietary needs and their likes and dislikes and personal preferences for food was in place. Copies of this dietary assessment and the resident’s personal preferences were provided for the kitchen staff. The residents are registered with a General Practitioner (GP). The system for recording GP visits enables staff to identify any changes in treatment the GP may have ordered for a particular resident. The manager advised that she regularly seeks advice and support from the community and hospital specialist nurses. A record of the involvement of two specialist nurses for two individual residents had been recorded in their plan of care. The specialist nurses had offered advice regarding the health care and treatment of the resident. This had been incorporated into their plan of care. One resident told the inspector that a hospital nurse had visited and had given the staff advice on how to help the sore on their bottom heal. They also commented that the treatment they had received had helped. The manager showed the inspector a letter from a consultant at the local hospital, which praised the care the home was giving to a resident. A record of sight and hearing test the residents had received were included in the plans of care for the four residents whose care was followed. The manager Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 12 confirmed that each of the residents has an assessment by an NHS registered nurse to determine their eligibility for NHS funded care. The medication practices were reviewed with the manager during the inspection. The resident’s medication was stored in a treatment room in locked cupboards and a locked medicine trolley. The manager advised that none of the current residents were taking controlled medication. A system for recording and disposing of controlled drug medication was in place. Two staff had signed the records of medication disposal. A clinical waste disposal company takes responsibility for removing the destroyed medication from the home. A system for disposing of controlled drugs using a recognised disposal system was in place. The manager advised that residents had their medication ordered on a monthly basis from the pharmacy using the GP repeat prescription. These prescriptions were available during the inspection. The inspector viewed two residents’ medication records. These had been completed and signed by the registered nurse administering the medication. Where new medication had been prescribed this had also been recorded in the residents plan of care relating to contact or visits from the residents GP. The manager advised that one resident was able to manage their inhaler with out assistance or supervision. The manager confirmed that she had observed this resident over a seven-day period using their inhaler and was satisfied that they were able. However a risk assessment had not been completed for this resident’s self-medication. Medication for two residents who had died the previous week was being stored at the home prior to disposal. The manager confirmed that these are kept for seven days following the death of a resident. One resident whose care was followed told the inspector that they had oxygen available in their room. They also advised that the manager had discussed this with them. A warning notice for oxygen was on the resident’s room door and the room identified on the fire plan for the home. A GP visited during the inspection, they saw the resident in the privacy of their own room. The manager confirmed that all personal care for residents is provided in their own rooms or disabled access bathrooms and toilets. The residents post was delivered during the inspection this was seen being given to the residents who were able unopened. The laundry system in place allows residents to receive their own cloths. Named individual storage baskets for residents were seen in the laundry room. The residents were wearing their own cloths, which were clean and pressed. The staff observed speaking to residents were using the residents preferred form of address, which had been recorded in their plan of care. One resident whose care was followed told the inspector that the staff had “asked them how they wanted to be addressed”. Another resident whose care was followed told the inspector that “the staff are very friendly and nothing seems to be too much trouble for them”. They further commented, “We are very well looked Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 13 after here”. Screening was available for the rooms, which were large enough for residents to share. Woodland Park Nursing Home DS0000028764.V310291.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provided for the residents appeared to be meeting their needs. EVIDENCE: The residents whose care was followed were asked about the activities provided at the home. Two of the four residents whose care was followed said they looked forward to the activities that were provided on a regular basis. A list of activities, which had taken place provided by Brixham activities and antics and activities were seen. The activities provided included movement to music, crafts and one-to-one with individual residents. The pre-inspection information indicated that musical entertainment is also provided. One resident told the inspector that they preferred to go out to the local pub or a long the seafront. The commented that they have good support for wheelchair maintenance; which enables them to use their wheel chair with confidence. They advised that they preferred not to take part in the activities provided by the home. One resident who had told the inspector at the last inspection that they didnt feel the activities were sufficient, reported that this had improved and then they were now satisfied with the activities provided for them. They Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 15 also advised that they had been unable to get out of the home more often than they had in the past. Visitors were coming in going throughout the inspection. They were seeing the residents in the privacy of their own rooms or one of the communal areas. One relative spoken to during the inspection said the staff are always friendly and helpful and keep them informed. They also commented that they were very happy with the care and support their relative is receiving the home. The care planning system in place identifies how the residents can exercise personal autonomy and choice over their daily routines. One resident told the inspector that they chose to stay in their own room and staff had enabled them to do this. The residents rooms entered had been personalised with items of their choice. This included photographs and small items of furniture. The lunchtime meal observed was unhurried and relaxed. The residents were eating their meals at their own pace. Staff were assisting those that required assistance in a friendly, supportive and discrete way. Three of the residents asked told the inspector that they look forward to mealtimes and usually enjoyed the meals. One resident told the inspector that the meals werent what they would have chosen for themselves but were usually reasonably prepared and presented. The manager advised that when residents didnt like what was on offer at lunchtime and alternative would be offered. A list of alternatives to the set meal was displayed on the wall in the dining room. Very little wastage was seen at the lunchtime meal. Staff were observed asking the residents if they wanted more food or an alternative to what was on offer. One resident was offered the choice of three desserts. A cold drink was available with the meal and a cup of tea provided for those who wanted it afterwards. Some of the residents had chosen to eat their meals in their own rooms. Others are sitting at tables in the dining room. The manager advised that the chef had completed a training course relating to the new food hygiene regulations introduced in January last year. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager must follow recruitment policy to ensure that the residents continue to be protected from unsuitable staff. EVIDENCE: The pre-inspection questionnaire listed the training staff had received since the last inspection. This included protection of vulnerable adults. The manager confirmed that all staff apart from the two that had just started had completed protection of vulnerable adult training. Four staff records reviewed during the inspection-contained information about the training they had completed. Copies of certificates were available on the file. All four staff files contained a job application form. Three staff files had evidence that the manager had obtained proof of identity. However not all the records listed in Schedule 2 were available in one of the staff files viewed. This new member of staff who had started work under supervision that week did not have any written references or proof the manager had contacted the referee by phone. A CRB was not available for this employee although the manager confirmed one had been applied for. Evidence that the new staff member had relevant pre employment checks completed for their employment was not provided. And no confirmation record that this had been applied for was provided. One staff members file contained Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 17 a copy of the CRB check provided their previous employer had completed this completed less than 12 months earlier. The staff observed during the inspection were speaking to the residents in a respectful friendly manner. The residents asked said staff are always polite to them and treat them with respect. Four residents asked said they knew who to speak to if they had any concerns and felt their concerns would be listened to. One resident advised that when they had raised a concern with the manager this had been dealt with promptly to their satisfaction. A record of complaints, concerns and compliments is kept in the home. This was provided for inspection. At the time of this inspection the Commission had received no complaints since the last inspection. Three residents comment cards all indicated that they knew who to complain to if they had any concerns. All three indicated that staff listed to them and acted on what they said. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 18 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): 19,22,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In order to ensure that the residents needs continue to be met; the manager should ensure that the equipment provided is able to meet their needs and is in good working order. EVIDENCE: New furniture had been provided in the residents lounge since the last inspection. The new chairs were domestic in character, easily cleanable and suitable for the residents needs. This had improved the overall look of the lounge for the residents. One resident told the inspector they thought the new chairs looked much better and they were comfortable to sit in. The manager confirmed that the remaining corridor, which needed the carpet replaced, was being completed later that week. The manager commented that the new contract cleaning staff who were supporting the homes own cleaning staff had made a difference to the home. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 19 One resident told the inspector they had to stay in bed because the hoist the staff used to help them get up was broken. The said that staff were “doing their best to ensure they had what they needed” but they were “getting a bit fed up with having to stay in their room”. The manager advised that the hoist had been broken since Sunday am, three days ago. She advised that she had borrowed a hoist from another home in the group. However this was not suitable for the resident. Another resident commented that the lift between floors had a broken operating button inside. This meant that they could not independently go between floors and had to rely on staff calling the lift from the first floor to return to their room and vice versa. They commented that although staff were more than helpful when they required this assistance it had taken away some of their independence. During the inspection a senior nurse from the organisation visited. They advised that a replacement hoist would be obtained as soon as possible for this resident. And the lift serviced to ensure it was fully operational. The home was fresh and clean in all areas entered during the inspection. The carpets in two residents rooms entered were slightly stained. The manager advised that the carpets are deep cleaned by the cleaner on a regular basis. And carpets are changed when the residents leave the home. One relative spoken to said “ staff keep their relatives room and the communal areas fresh and clean”. Three residents comment cards indicated that the home is always/usually fresh and clean. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are cared for by a staff team who treat them with respect and value their opinions. However by not following the homes recruitment policy for all staff, residents may be put at risk from unsuitable staff. EVIDENCE: Two members of staff were spoken to during the inspection and one comment card was received from a carer. One relative was spoken to during the inspection and three relatives comment cards were received. A duty rota showing the names of the staff, what capacity they were employed in and their hours of work for each shift was available. Two relatives comment cards indicated that they did not feel sufficient staff were on duty at all times. Two staff members commented that they felt well supported to do their work and were given the opportunity to complete training that enabled them to do their work well. They also commented that there was a good team of staff at the home that worked well together. However they did raise concerns about the extra shift they were doing to cover for staff number shortfalls. They also commented that when staff are off sick at short notice sometimes it is difficult to get cover meaning they do not have as much time to care for the residents, as they would like. The manager confirmed that she Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 21 had interviewed new staff and two would be working as soon as the relevant checks had been returned. However one new member of staff working under supervision did not have any of the pre employment checks provided in their file. The manager advised that she had followed up telephone references and was awaiting written references. She also said she had seen a CRB from their previous employer. However copies of these or notes of telephone conversations were not recorded in this staff member file. The manager agreed that this member of staff probably required other documentation. However a copy or record of this being seen had not been recorded in the staff members file. This staff member had started work at the home last week under supervision. All other staff files viewed during the inspection had the records and employment checks completed and contained in their staff files. A matrix checklist system had been used to identify the employment checks received for the staff. This indicated that apart from one new member of staff noted above. The manager confirmed that all employment checks and documents required were in place for other staff employed. The pre inspection questionnaire indicated that 5 of the 10 care staff employed had an NVQ level 2 or above. The staff spoken to during the inspection told the inspector that they had been encouraged to complete their NVQ training by the manager. They also commented that they were given time to study. The manager provided examples of the induction process completed by staff. She advised that all new staff have an induction programme the length of time it takes depends on the skills and training needs of the individual staff member. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. The manager continues to foster an open atmosphere where the residents, their family, friends and staff, feel valued. However the some aspects of management have not fully protected the residents. EVIDENCE: The registered manager has several years experience managing a care home. She advised the inspector that she had started the NVQ level 4 in management. Information is available for staff in the office regarding conditions and diseases that affect the residents at the home. There are clear lines of accountability within the home. The staff commented that the manager is approachable and helpful and listens to their concerns. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 23 The manager advised that the views of the residents their relatives and other professionals are sought on a regular basis. The results of previous quality audits were available in the office of the home. However this had not been made easily available for the residents to see. The manager advised that the organisation had adopted a policy, which meant service users money, was not held on their behalf. And an invoicing system had been adopted for individual residents. The manager confirmed that no one in the home acts as appointee for any of the residents. The training records provided for staff indicated that they receive regular manual handling training and instructions on fire safety. The staff records reviewed showed that food hygiene, some staff had also completed first aid and infection control training. The pre-inspection questionnaire indicated the training staff had completed since the last inspection. This included protection of vulnerable adults, food hygiene, health and safety, infection control continence care and care of the dying. The manager also confirmed that tissue viability training and NVQ training were planned. Health and safety policies and procedures are easily available for staff in the office. A record of maintenance completed was also available for inspection. The pre-inspection questionnaire indicated that equipment and health and safety checks have been completed in line with the practice. A copy of the risk assessments completed for the environment and individual risks the residents take the provided. The accident record book was seen this had been completed as expected. The manager advised that she regularly reviews the accidents and looks for trends in any action that can be taken to reduce risk. The manager had not ensured that the all staff had received the appropriate pre employment checks before they started work. This could put the residents at risk from unsuitable staff. The manager had not ensured that the manual handling equipment for one resident was suitable for their needs. This had disadvantaged the resident. The health safety and welfare of the residents may be put at risk if the equipment they need is not in good working order and staff are not fully checked before they start work. Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 24 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 x x 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 3 x 2 Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 25 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 OP18 Regulation 13(2)23(4 )(c) Requirement The registered person shall not employ a person to work at the home unless he has obtained in respect of that person the information and documents specified in schedule 2 The manager must provide confirmation of CRB checks being completed for all staff Requirement from the last inspection not fully met time scale extended from 30.11.05 and 31.07.06 The registered person shall not employ a person to work at the home unless he has obtained in respect of that person the information and documents specified in schedule 2 The manager must provide confirmation of CRB checks being completed for all staff Requirement from the last inspection not fully met time scale extended from 30.11.05 and 31.07.06 Timescale for action 31/03/07 2 OP29 19(1b) Sch 2 31/03/07 Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 26 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 OP19 Good Practice Recommendations Registered person should having regard to the number the needs of the service users ensure that the premises to be used as the care home are of sound construction and kept in good state of repair externally and internally. The routine maintenance and redecoration of the home should continue until all areas have been refreshed The manager should ensure that equipment (hoists) the service users need are suitable to meet their needs. The manager should complete a recognised management award Copies of the completed quality audit should be made available for the residents. The manager should ensure that the residents health safety and welfare is protected by the management systems in the home. 2 3. 4. 5. OP22 OP31 OP33 OP38 Woodland Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Park Nursing Home DS0000028764.V310291.R01.S.doc Version 5.2 Page 28 - 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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