Inspection on 16/04/08 for Woodland Villa

This inspection was carried out on 16th April 2008.

CSCI found this care home to be providing an Good 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 Villa 06/11/07

Woodland Villa 13/02/07

Woodland Villa 24/05/06

Woodland Villa 10/02/06

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Woodland Villa 93 Alma Road Plymouth Devon PL3 4HE Lead Inspector Megan Walker Unannounced Inspection 16th April 2008 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 Villa DS0000064463.V362567.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 Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Villa Address 93 Alma Road Plymouth Devon PL3 4HE 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) 01752 669625 01752 250123 annamcglew@yahoo.co.uk Denmax Ltd Mrs Anna Kathryn McGlew Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (5), Physical disability of places over 65 years of age (34) Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Old age, not falling within any other category (19) Physical Disability over 65 years of age (34) Physical Disability (5) There should be no more than a maximum of 5 (five) service users in the home at any one time between the ages of 50 years to 65 years. 6th November 2007 Date of last inspection Brief Description of the Service: Woodland Villa is a care home with nursing that is registered to provide personal care for up to 19 clients, and nursing care for up to 34 clients. It can therefore admit up to 53 clients over the age of 65 years old and of either gender. Registered nurses manage the nursing unit 24 hours a day and are supported by care support staff that have received training in providing care safely. Woodland Villa has been developed over several years from a row of large terrace houses that have been linked internally, and has been adapted to meet the demands placed upon it by the people living here, many being disabled through illness. It is on the outskirts of Plymouth city centre and is on the bus route to the city centre. There is access also to some local amenities. The home presently has a residential unit at one end and the nursing home takes up approximately two thirds of the property. There are separate entrances although ramping and passenger lifts have been provided to enable people access to all parts of the home. There are shared communal spaces of good proportions at each end of the building. These are attractively decorated and offer several separate areas, including a library, for people to sit in with each other or with their visitors. There is a small outdoor area that has some seating for people to use in times of good weather. The home has a car park available for visitors or there is on-street parking close by. Fees range from £288.00 to £468.00, (up to £520.00 for ‘continuing care’), and are according to assessment of the person’s personal and nursing care needs. Additional charges include hairdressing, chiropody, toiletries, newspapers, magazines, journals etc, all charged at commercial rates. All charges’ information was provided to the CSCI in April 2008. There is a copy of the home’s Statement of Purpose and previous CSCI inspection reports in each entrance hall. Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 5 Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a Key Inspection undertaken by one regulation inspector. The fieldwork part of this inspection was unannounced and took place over two days, Wednesday 16th April 2008 between 10h30 and 18h30 and on Friday 18th April 2008 between 07H30 and 16H30. This inspection included talking to people who live at the home and their families, day and night staff, and visitors to the home. Also, observation of interactions between staff and people using this service, a tour of the premises, and inspection of care plans, staff files, medication and other records and documentation. The Registered Manager and the Registered Provider were present on both days. They were able to provide relevant information such as the day-to-day routines as well as the management of the home. The Registered Provider also gave us an update on the refurbishment and redecoration plans for the home. This report also includes references to seven random inspections of the home that took place in December 2007, January and February 2008. There were two inspectors on each occasion and on one occasion a nurse from the Health Protection Agency accompanied us. The purpose of the random inspections was in response to a number of complaints and concerns we received. We did not find any evidence of deliberate neglect or anyone intentionally meaning to cause harm to anyone using this service. We found that there was evidence of poor practice. We found a combination of a long-term institutional attitude to supervision, practice guidance and training mixed with a change of owner and manager. During this period the local authority has restricted the home’s admissions. The Registered Provider completed an Improvement Plan based on the requirements from the last Key Inspection, with realistic timescales and returned it to the CSCI by the date required. “Have Your Say About Woodland Villa” Care Home Surveys were given out to people living in the home, their families, and to staff. Six people using this service and one relative had completed and returned surveys to us by the time this draft report was sent to the Registered Provider. Some of the comments include: “Pity all homes are not as good as here.” “I have always felt happy and safe in this home.” “I really cannot praise them [staff] enough and I would recommend the home to anyone.” “The food is excellent.” [Meals]”Varied and well presented. Special needs catered for.” Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 7 In addition other information used to inform this inspection: • The Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager for the last Key Inspection. • The last Key Inspection report • Letters and telephone calls from families of people living at Woodland Villa wishing to express their overall satisfaction with the care home. • All other information relating to Woodland Villa received by the CSCI since the last inspection. No requirements were made as a consequence of this inspection. What the service does well: What has improved since the last inspection? As a consequence of the random inspections and the issues identified, the care staff are much more focused on the people living in the home, working to improve services, and to protect people from abuse and harm. Care plans are more personalised and specific about individual peoples needs. Changes to staffing has improved the daily quality of life for the people living at Woodland Villa: • Two new posts – Activities Co-ordinator responsible for daily activities and a Liaison Nurse who is responsible for e.g. arranging medical appointments, hearing aids, dentist and optician appointments, etc. • A senior carer is now responsible for overseeing infection control practices around the home. • The reorganisation of the staff rota to provide more staff on duty early morning and a twilight shift, and the introduction of staff rotation between day and night shifts. Families who visit regularly have been asked to feedback to the Registered Provider their comments and observations on any matters that they may notice during a visit to the home. The complaints procedure has been revised. It is prominently displayed in the care home. Guidance has been made available for all staff to understand how to respond to complaints and concerns. Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 8 The medication system has been audited and new documentation is in place from the pharmacist who dispenses medication to Woodland Villa. Generally the care home is more ordered and tidy. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to use this service and their families can feel confident that their needs will be assessed before moving into the home and that they can have the information they need to make an informed choice about where to live. EVIDENCE: Anyone considering moving in to Woodland Villa is offered an informal tour of the home and an opportunity to talk to people using the service. Their family or friends may do this on their behalf. A copy of the home’s Statement of Purpose (also called a brochure) and scale of care fees are given to everyone moving into the care home. We looked a copy of this and it needed a few minor amendments to update it. The Registered Provider has provided a copy of a previous inspection report with the Statement of Purpose and any other Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 11 information that would be useful for prospective residents in each of the entrance areas of the home. On the last Key Inspection we inspected three care files and found good preassessments of care needs, completed by the Registered Manager. People move into the home for a variety of reasons. They may have made a private arrangement, or the local authority may have referred them to the home via the Social Services Department, the RITA scheme (a short term rapid intervention team that enables people during a ‘crisis’ period to have a short respite stay, without the need, necessarily, for hospital admission). Some people are assessed as requiring continuing care and are supported by the local Primary care trust (PCT). There have been no new admissions this year due to the local authority’s restriction on people moving in to the home. Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service can feel confident that a staff team that is respectful and sensitive will ensure that all their health, personal and social care needs are met. EVIDENCE: We chose five people, both women and men, to look at their care files and care generally because they were, for example, people who had no visitors, people with more complex needs (such as health care needs), and people with changing needs. Inspection of these care files found that these were greatly improved from previous inspections and were person-centred. Each one had a detailed assessment of care needs and a care plan. These identified what the person was able to do for her/himself, and what support or help was needed from staff. This included assistance needed with personal care, preferred activities, Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 13 dietary likes and dislikes, allergies, how people might show they were in pain if they did not complain verbally about it, any actions staff needed to take, such as a risk of sore skin, or recognising changes in blood sugar levels for someone who is a diabetic, for example. Where cot sides were needed on the bed for reasons of safety, this had been documented in the care plan with a risk assessment. The people we spoke to, and in the surveys returned by people using this service and their relatives, they told us that the care they received was good, and staff were caring. “The care and attention given was first class. The staff couldn’t have been more helpful.” [Following surgery]”Staff all helped me”. “On our visits we are kept informed about ‘x’’s health, and any visits from the district nurse or doctor. The recently appointed Activities Co-ordinator had started to gather “Personal Stories”. Those seen varied in the amount of detail however it was evident from reading these that the information had been gathered by consulting with the individual resident. This background information is considered important by the home’s staff because it helps to build the bigger picture of the resident as a person, why s/he may behave in a certain way, have expectations for the way in which s/he lives her/his daily life. It is intended that this information will be focused into planning an achievable plan of care for each individual. The introduction of a liaison nurse has given people a designated person to whom they can request assistance such as sorting out appointments for opticians, dentists, and hearing aids. All the care plans seen had been reviewed regularly and amended as required. When a resident had had an accident this was recorded appropriately and reported to the relevant authorities if necessary. The daily records were greatly improved, more focused including times and details of relevant information about any care provided. The local pharmacist has audited the medication. It is expected that a new dispensing system will be in place shortly. This is pending the arrival of new, more suitable drugs’ trolleys. The treatment room was orderly and tidy on both days of this inspection. A keypad has been fitted to ensure that it is kept locked at all times. Three people’s medicines were checked. These were all in date and the correct number of tablets was in the boxes. Inspection of the medication record sheets Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 14 found they were all signed appropriately when medication had been given. Each one had a photograph of the individual and any known allergies were also recorded on the individuals medication record. There was a procedure about contacting general practitioners if individuals refused medication on more than one consecutive occasion. General practitioners were being asked to review and document changes of medications regularly. We spoke to people as we walked around the building and asked them about living in the home. Everyone we asked was very positive about the staff and felt that they were treated well, with respect, and their care needs were being met. It was also evident that staff were paying attention to peoples’ personal care, for example nail care, hair, and encouraging people to wear jewellery and makeup if they so wished. Woodland Villa DS0000064463.V362567.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living at Woodland Villa are satisfied with their lifestyle and are encouraged to exercise choice and control over their lives. People are supported to continue to enjoy familiar supportive relationships with family and friends, and within the local community. EVIDENCE: One person who has lived at the home about a year told us that they were “well looked after”. Another person told us that they are “happy living here”. Two other people who have lived here much longer said that the staff were helpful and friendly. People told us they were able to choose whether they stayed in their room or went out into the lounge to join in activities and conversations with other residents. One person told us we cannot fault the care, staff do everything they can. Obviously there will be a few errors. People living in the home also told us that their families are able to visit when they chose, there were no restrictions on visiting. All our inspection visits we have seen families, friends and carers calling in to the care home. One family Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 16 member told us that they found both the Registered Manager and Registered Provider to be approachable, willing to listen to compliments and concerns they may raise with them. Since the last key inspection a full-time Activities Coordinator has been appointed. On both days of this inspection visit there was a lively atmosphere around the home. There was a small group who told us they like to meet up at coffee time in the mornings to chat and knit together. With the recent provision of a dining table in the Garden Room, another group has taken advantage to use this for playing cards and other board games. A staff member who worked night shifts told us about a resident who had been telling her about a card game he had been playing. There was a white board in the entrance hall with the list of activities for the day on each of our visits. These activities took place around the home and also included some one-to-one time for individuals to sit and chat with the coordinator. Other staff members told us they found people were generally much brighter and keen to come out of their rooms into the communal lounges to be with their peers. On the previous key inspection we found that one of the lounges was being used for staff training and people were restricted to their rooms. Since that inspection the Registered Manager has been pro-active in ensuring that either a smaller area is used if the training is only for small group of staff, or that people are encouraged to use the other communal areas around the home. Consequently she has found that for some people this arrangement has worked much better and those people now choose to go to a different lounge where they are more comfortable and interact with their peers. In a survey returned by someone using this service they wrote: “I am free to join in any of the home’s activities if I wish, but I do enjoy the peace and quiet of my own room.” Since the last key inspection a new cook has been appointed. On this visit we spoke to both cooks. They were compiling new menus that would be printed out daily. We saw an example of this and it was well presented. People were asked the day before for their choice of meals however they could change their mind on the day. At lunchtime people were able to choose where they ate. Some people chose to go to the dining room whilst others preferred to sit in the lounges. We saw that there was a selection of meals being given to people for example fried or poached fish, omelettes, jacket potatoes, sandwiches and curry. We observed staff asking people what they would like before the food was dished up. The cooks prepare the evening meal and on the day of this visit it was a homemade egg and bacon pie, thick soup and a selection of sandwiches. Cakes and pastries are made on the premises daily. A member of staff who worked night shifts told us that the kitchen is open throughout the night and if a resident is hungry, the night staff were able to make snacks and sandwiches for them. The cook had told us that people could have eggs for breakfast. Someone living in the home we spoke to at breakfast time said that they were always asked what they would like to eat. They confirmed that eggs Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 17 were always available at breakfast time as well as porridge and cereals and toast. In surveys returned by people using this service they wrote: “The food is excellent” “Varied and well presented. Special needs catered for.” Woodland Villa DS0000064463.V362567.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Woodland Villa and their families and friends can feel confident that any issues of concern or complaints raised by them will be dealt with appropriately. EVIDENCE: In each of the entrance reception areas there was a box with suggestion and complaint forms. There were also Care Advocacy Service leaflets, and a copy of the Help The Aged ‘Life in a Care Home’ booklet. The complaints procedure was clearly displayed in both entrance halls although the contact details for the CSCI needed to be updated. The complaints procedure for the home has been revised and guidelines have been given to all staff so they know what they should do if they receive a concern or complaint. This includes a flow chart that makes it much easier to follow through the process. A relative told us that they found the Registered Manager and the Registered Provider to be approachable and willing to listen about any matters of concern and were opened to constructive criticism. Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 19 We have made enquiries into all the concerns that were brought to our attention by families, and by staff who have chosen to remain anonymous, between November 2007 and April 2008. We visited Woodland Villa on several occasions during this period. A nurse from the Health Protection Agency has visited the home regarding the anonymous staff concerns about alleged poor practice causing risks of cross infection. We did not find any evidence of deliberate neglect or anyone intentionally meaning to cause harm to anyone using this service. We found that there was evidence of poor practice. We found a combination of a long-term institutional attitude to supervision, practice guidance and training mixed with a change of owner and manager. As a consequence of all our findings, the Registered Provider agreed to implement changes to staff training, staff supervision and staff rotas. Changes were made to the Employees Handbook and the staff contract was revised. The Registered Provider was encouraged to use the disciplinary procedure as described in the Employees handbook when it was deemed necessary to take such action. All the staff were asked to provide the relevant documents to renew all the Criminal Records’ Bureau (CRB) checks (police checks). The Registered Manager has put in place measures to minimise risks with regards to the handling and administration of medication and the storage of medication. We received an Improvement Plan from the Registered Provider about how he intends to minimise risk and to develop this service for the benefit of the people who use it. Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use this service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: Woodland Villa is undergoing a major refurbishment and the work already completed enhances and improves the facilities for the people living in the home. It is an old Victorian building and the Registered Provider has encountered many major unexpected difficulties that have added cost and time to the planned works. This includes the heating system and all the electrical wiring. An engineer had called at the home during this visit about the boiler Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 21 and it was hoped a new boiler would be fitted by the end of May 2008. At the time of this visit the registered provider was hoping to progress with plans for the installation of a new kitchen. This too was planned for the end of May 2008. In light of this Registered Manager was intending to write to families and representatives advising them that there would be temporary arrangement for the provision of meals. As we walked around the home it was found to be clean and tidy. There is a team of domestic staff who have all been trained in infection control, lifting and handling, and health and safety at work. There have been some concerns that the domestic staff team do not speak English as a first language. From all our visits over recent months we have not had cause for concern that this staff team is unable to understand or to carry out their duties responsibly and appropriately. On this visit we observed communication between a cleaner and another staff member. Although the English was limited this was not a barrier to comprehension. The Registered Manager advised us that for training purposes provision has been made for translation for staff that do not speak English as a first language. Wheelchairs and other equipment were stored in cupboards. Portable radiators seen in use at the last key inspection had all been removed. Hot water taps had been regulated and window restrictors were fitted as part of the ongoing maintenance program. A number of the bedroom doors identified on previous visits not self-closing had been checked to ensure they close properly. People who like to have their door open have had door guard devices fitted. These are compliant with the fire alarm and when tested in conjunction with the fire alarm they worked. The Registered Provider had arranged for the door of the en-suite for a double room on the ground floor to be blocked so that access would be from the bedroom only thereby ensuring the privacy and dignity of the people using the bedroom. [We found on the previous key inspection it could be opened from the bedroom and the hairdressing room.] Bedrooms were personalised. Some of the bedrooms had a clinical feel to them however people were encouraged to bring in their own pictures to be put up on the walls for them, and have their personal possessions around them. A relative told us that on the occasions that he visited Woodland Villa with another family member, he found that staff were very caring, looking after residents well, and the home was clean and pleasant smelling. Another relative told us that in the past 18 months the level of care of her mother have improved greatly, there are more activities for the people living at Woodland Villa, and there is a new security system fitted on the front door. Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Registered Manager and Registered Provider are taking steps to ensure people receive a safe basic level of care. Staffing arrangements are more robust to assure people that suitable and competent staff can meet their existing and changing needs. EVIDENCE: The people we spoke to about living at Woodland Villa were content and told us that the staff were caring, kind and respectful. Relatives told us that care standards had improved over recent months and that they were always made to feel welcome when they visited the home. Staffing levels at Woodland Villa are good. At the time of this inspection visit there were 35 people living in the care home. In the mornings there are nine care staff, a trained nurse and the matron; in the afternoons there are seven staff, a trained nurse, and the matron. A twilight shift has been introduced from 19h30 22h30 with one extra staff member in addition to the four night staff and one trained nurse. This allows people more choice about what time they go to bed. As an outcome of one of our random inspection visits when we found that the night staff were waking some people early for breakfast, the Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 23 staff rota has been changed. Now four of the morning staff start at 07h00. This means that there is a total of eight care staff to assist people who need help with eating and drinking as well as taking breakfast to people in their rooms. In addition to all the care staff and trained nurses there is a dedicated ancillary staff team responsible for domestic work, laundry, and maintenance. There are two cooks who split the week between them and work from 08h00 to 17h00 daily. There is a full-time Activities Coordinator who works Monday to Friday, a deputy manager who is responsible for all the administrative tasks of the care home and a Liaison Nurse has been appointed to oversee medical appointments, hearing aids, glasses, dentures, etc. An internal staff rotation has been introduced. All new staff are expected to rotate between nights and days. Current staff have also been offered this option however it is optional if they have a contract stating defined hours of work. Staff have recently been sent a survey and this includes questions about shifts and the length of shifts. The Registered Manager told us that she would like to reduce the number staff working twelve-hour shifts because staff become overtired. The people living at Woodland Villa are protected by much more robust staff recruitment procedures. Inspection of a random selection of six staff files found that they all had evidence of the relevant required checks having been completed. They all had the legally required checks including Criminal Record Bureau (C.R.B) checks and “Protection of Vulnerable Adults” (P.O.V.A.) list checks (i.e. police checks). We were told that a staff member who was relatively new was still awaiting the return of a C.R.B. check. The Registered Manager confirmed that this person works under supervision and does not do any personal care. We spoke to this staff member who confirmed this to be the case. Three of the six files had a copy of their contract. The other three people were pending the end of a probationary period and induction. The job descriptions and staff handbook were revised and provided for each staff member. The application form had been changed and was much clearer to complete. This included a dedicated page about declaring any criminal convictions or cautions. There was evidence of in-house induction training for each staff member. Also there was evidence of an ongoing training and development programme. Next to the treatment room we saw a training notice board. There was a variety of training courses available to staff including wound management, pressure ulcers, emergency first aid, dealing with challenging behaviours, and legal and ethical issues in nursing. All senior care assistants will be attending an advanced medication management course in May 2008. Senior carers have recently attended a Food Safety Awareness training course, and all staff have attended safeguarding vulnerable adults training. The Registered Manager confirmed that more training was being organised for staff that had started working at home more recently. The Registered Provider pays for all staff training. The courses that were advertised on the training board were available for any staff that may have a particular interest. Staff are Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 24 encouraged to attend any extra training in addition to being expected to attend all mandatory training. Observation of staff working practices during this visit found that they were confident about their jobs and from conversations with staff it was evident that they enjoyed working at Woodland Villa. We spoke to staff finishing the nightshift as well as staff working during the day. Three staff members told us that they felt things were much better now and there was more team working. They all spoke about improved recording in care plans, including all contacts with residents during the night. One staff member told us there seemed to be less staff sickness and people phoning in at the last minute or not turning up for work. One staff member commented that it was great having an Activities Coordinator. The residents seemed to be much brighter and happier and like coming down to the Garden room to join in activities. On the second day of our visit two staff members independently told us that they have been told to record exactly what people had eaten or drunk on the care records. [This was an observation that was made on the first day of this inspection visit. The matron had been advised that if this information was to be recorded, it needed to contain relevant detail rather than for example “All lunch eaten”.] Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 25 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 good This judgement has been made using available evidence including a visit to this service. The people living at Woodland Villa can feel confident that their health, safety and welfare is promoted and protected by a competent and capable Registered Manager and Registered Provider who are keen to achieve positive outcomes for everyone. EVIDENCE: The Registered Manager is actively involved in the day-to-day running of the home and responsible for staffing and overseeing the provision of care. The management of the home was transparent and honest. On all our visits the Registered Manager was found to be approachable. She was keen to promote Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 26 the welfare and general well being of the people living at the home with no discrimination or pre conceptions. The Registered Provider is introducing a computer system for use by all the care staff. This has different levels of access for different staff, it is encrypted and can only be accessed with a password. In due course is it intended that all care staff will be trained to record information using this computer system. Questionnaires have been given out to everyone living in the home and their families and representative. They have also been given out to social workers, district nurses and doctors who visit the home. One of the trained nurses was collating the responses as they were returned. The Registered Manager and the Registered Provider will then implement any necessary changes. People can choose to manage their own finances or their representative on their behalf. The Liaison Nurse deals with anyone who chooses to have their monies held at the care home. This was seen kept in a lockable cupboard in the Registered Manager’s office. Details were recorded to show any money spent, receipts kept for cross reference and all the personal monies were checked by two people on a regular basis. People could ask for their money at any time and also to check it for themselves (with a relative if appropriate). Only the sister in charge has a key to this cupboard. It also used to store medication. Subsequent to the requirement made at the last key inspection, all incidents that affect the health, safety and/or well being of people using this service are now reported to the CSCI as required by Regulation 37 of the Care Homes Regulations 2001. The Fire Log book was up to date and fire alarm tests were recorded. A fire safety lecture was held at the home at the end of September 2007 that most staff had attended. The last Environmental Health Officer’s (EHO) inspection was in March 2008. Each bedroom had a soap dispenser and a hand towel dispenser fitted as a preventative measure for cross-infection. The Registered Provider and Registered Manager had resolved the concerns we had about health and safety matters on the previous key inspection. This included: • Portable heaters that were potential trip hazards had been removed. • Electrical items been tested for electrical safety. • Doors were self-closing properly so were no longer a fire safety risk. • Windows were restricted. • Clean bedding/ linen and general dressings stored on ‘back’ trolleys were gone and other storage arrangements were in place. • Hot water taps were regulated so people were not at risk of scalding/burning themselves. • All the dustbins had been moved to the other end of the car park away from the entrance. All the maintenance records were together in a file. The Registered Managers office and the Treatment Room were tidy and arranged in an orderly manner. Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 27 It was much easier than on previous visits to find records, policies and procedures. Woodland Villa DS0000064463.V362567.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 3 x 3 x 3 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 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 4 x x 3 Woodland Villa DS0000064463.V362567.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodland Villa DS0000064463.V362567.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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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