Inspection on 01/03/07 for Woodlands Care GRP Ltd

This inspection was carried out on 1st March 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 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

Woodlands Care GRP Ltd 28/08/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodlands Care GRP Ltd 22 Woodlands Drive Atherton Manchester M46 9HH Lead Inspector Judith Stanley Unannounced Inspection 1st March 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Care GRP Ltd DS0000067718.V319997.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. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Care GRP Ltd Address 22 Woodlands Drive Atherton Manchester M46 9HH 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) 01942 875054 01942 875054 Woodlands Care GRP Ltd Mrs Janet Hope Care Home 30 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (30) of places Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 30 service users to include: up to 30 service users in the category of Older People; up to 10 service users in the category of DE(E) (Dementia over 65 years of age). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The service should at all times employ suitably qualified and experienced members of staff, in sufficient numbers, to meet the assessed needs of the service users with dementia. The service should ensure that all staff receive training in dementia care and ensure refresher training also takes place. New Registration. 2. 3. 4. Date of last inspection Brief Description of the Service: Woodlands offers personal care and support for up to 30 residents over the age of 65 years. Included in those numbers the home can offer care to 10 residents with a dementia related illness. Woodlands is on the Bolton and Atherton border and is set back off the main road up an unmade road. Local amenities are a short drive away from the home. The home is a large detached house set in it’s own grounds with wellestablished gardens to the front and the rear of the home. The garden at the rear is private and secure. Limited car parking is available at the front of the home. The home is a two-storey building with bedrooms, bathrooms and toilets on both floors. The home offers 26 single rooms of which 6 have en suite facilities and two double rooms of which 1 has an en-suite facility. There are three lounges and a separate dining room. The current scale of fees range from £304.84 to £370.00. For self-funding residents the fee ranges from £360.00 to £385.00. Additional charges are made for private chiropody, hairdressing, personal toiletries and pet food and pet costs (a resident has brought her cat with her when she moved into the home). Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to Woodlands took place on 1 March 2007 and included a site visit. The inspection was carried out over 7½ hours on one day. The homes manager was available at the start of the inspection and returned for feedback at the end of the inspection. Her absence was due to a prior training commitment. The senior carer on duty assisted with the inspection. The inspector looked at records the home holds on residents (care plans) and other records the home needs to keep to ensure the home is being properly run. The inspector looked around the home, spoke with staff, residents and visitors. To find out more about the home comment cards were sent to residents, relatives and other visiting professionals for example doctors, chiropodist, and district nurses asking them what they thought about the service and the care provided. Nine residents returned comment cards, one from a chiropodist, one from a doctor and eight from relatives. From the nine residents returned cards there was no added comments made, however the boxes ticked indicated that residents were satisfied with the care provided. The chiropodist and the doctor indicated they had no concerns about any of the care practices they had seen when visiting the home. One relative said, “my mother has received nothing but kindness and helpfulness at all times especially at the beginning when it was all strange. I cannot complement the staff enough”. Another said, “ I am very pleased with the care my relative receives, the staff are always cheerful and ring me if there are any problems. My relative is happy in their care. Information received prior to the inspection indicates there had been no complaints made about the service since the new company took over and no complaints have been brought to the attention of the CSCI. What the service does well: The home provides different areas for residents to have a choice as to where they sit and with whom they chose to spend time with. The home welcomes visitors at any time and makes them feel welcome. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 6 Some staff have worked at the home for several years. This helps provide consistent and reliable care for people living at the home by staff they know and are familiar with. What has improved since the last inspection? What they could do better: On the day of the inspection there was not enough staff on duty to meet the needs of the residents. At least seven staff had a diagnosis of a dementia related illness. Some residents require two members of staff when using the hoist to transfer them. It was also noted that the dependency levels of some residents appeared high. One member of staff had not received moving and handling training yet was observed moving residents. One member of staff was working without a Criminal Records Bureau Check (CRB). Fire doors in the corridor were wedged open and one door was fastened back with a hook. The fire door to the kitchen was open. All fire doors must remain closed unless fitted with a fire door guard that is linked in to the fire alarm system and will automatically close on the alarm being activated. There should be enough staff to assist with feeding residents that require assistance at meal times. It was observed that at least three residents were struggling to eat their meals, and staff eventually removed plates of uneaten cold food, therefore residents had not had sufficient to eat. Staff were busy feeding residents in the lounge area leaving the dining room short staffed. The pureed diet should have all foods individually pureed to allow residents to taste the different flavours, textures and colours. Not all staff had received training in the protection of vulnerable adults. The manager has not carried out regular staff supervision sessions as required. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 7 All debris and rubbish from the front and rear of the home should be removed or stored in a skip until the work on the building is completed. This looks unsightly to residents and visitors. The home would benefit from some additional domestic hours as on the day of the inspection; the domestic was doing the laundry and the cleaning. This is a big home for one person to maintain. It was apparent that during discussion with staff that certain tasks are allocated to certain people to do at certain times. For example the night staff clean the lounges and stairs, however regardless of by who and when the job is done, the stairs were full of what looked like cats biscuits that had spilled out of a bowl when the resident brought the dish downstairs. These remained on the stairs all day and looked unsightly and resulted in them being walked into the carpet. In order to respect resident’s dignity, one gentleman who is immobile was shaved in the lounge by staff in front of the other residents. This is not good practice and the manager must ensure that personal care is offered in the resident’s own room. It was observed that the lunchtime medication was given out in the middle of lunch. Unless stated, the medication would have been better given at the end of meal, freeing the senior carer to assist helping people with their lunch. 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. Woodlands Care GRP Ltd DS0000067718.V319997.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 Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 was assessed. Standard 6 does not apply, as Woodlands House does not provide intermediate care. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and their supporters with up to date and relevant information about the home and the services and facilities they aim to provide. Pre admission assessments are in place to ensure the home can meet the assessed needs of the residents. EVIDENCE: The home has recently amended the service user guide and the statement of purpose as the home has changed ownership. Both documents were submitted to the CSCI prior to the new company being registered. Information is available in the home to help prospective residents and their supporters make a decision about moving into the home. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 10 Four residents files were chosen for inspection. On examination all contained a pre admission assessment to ensure the resident’s health, personal and social care needs could be met. The assessment covers residents general wellbeing, risk, mobility, continence, personal care, medication, nutrition, oral care, foot care and skin care. Assessments are carried out at the most convenient place for the prospective resident, either at their own home, in hospital or at Woodlands House. The assessment provides staff with information they need to ensure that the individuals care needs can be met and provides the base line for the drawing up of the care plan. Woodlands Care GRP Ltd DS0000067718.V319997.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, and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were satisfactory and provide staff with information they need to meet the needs of the residents. EVIDENCE: Four care plans were chosen for inspection. The information contained provided staff with information about the care each resident required. Two of the files looked at had not been updated monthly as required and there was no evidence to show that the resident or relative had been consulted in the drawing up and in maintaining of the care plan. Other information in the care plans included risk assessments for moving and handling, any hazards, dietary requirements, continence, mental state and skin care. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 12 There was evidence to demonstrate in the care plans that outside agencies, such as the resident’s doctor, the chiropodist and district nursing team are contacted as required. Observations throughout the inspection showed that in the main the personal care needs of the residents were being met. It was noted that residents were clean, tidy and nicely groomed and had had their hair done. One gentleman who is immobile was seen sitting in his recliner chair in the lounge with the other residents, mainly ladies. The inspector observed staff proceeding to shave the gentlemen in the lounge in front of residents. This is not good practice, but when staff were asked about this it appears to be custom and practice for this to happen. All residents should receive any personal care in the privacy of their own rooms. The carer who assisted the gentleman to get up, washed and dressed that morning should have completed this task prior to taking him into the lounge. It was noted that there was a respectful, friendly banter between the residents and staff and that good relationships had been formed. One resident spoken to said that the staff are, “very nice and caring and work hard, but sometimes there appears to a shortage of staff”. The inspector witnessed on the day of the inspection that staffing were struggling to meet the needs of the residents. The senior on duty was observed giving out the lunchtime medication. The inspector saw that the tablets were given appropriately and with water to help residents swallow the tablets. The timing of when they were given was not satisfactory, as this was done in between the main course and the dessert. Although the medication was recorded immediately on the resident’s individual drug sheet, the whole process appeared to be chaotic and unless stated that the tablet should be given in between courses this practice needs to be reviewed before an error in medication occurs. It was noted that in the general office there was a basket with residents prescribed creams on the shelf, these must either be stored in the residents own room or in a more suitable place. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities and the meal/mealtimes need to be reviewed to ensure that residents have a meaningful purpose to their day and that they receive a wellbalanced and nutritious diet of their choice. EVIDENCE: The homes activity file was available for inspection and indicated that a range of activities is provided, including facials, hand care, entertainers, bingo, dominoes and exercise. During the inspection the local clergy arrived to offer communion to those residents who wished to partake. Comments on returned comment cards from residents indicated that there activities available sometimes, but from speaking with three residents it appeared these took place depending on the staff time to carry them out. As the dependency levels of several resident’s appears high and several residents have a diagnosis of dementia the activities programme would benefit from being reviewed to ensure there is something for everyone. It was noted that one member of Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 14 staff did sit in the afternoon for a short time and read and discuss articles from the paper. Other residents were mainly left to their own devices and watching television. Two visitors were spoken with and were happy with care provided. One made comment how clean the home was and that he was always made welcome when he visited his relative. There are no restrictions on the times when people can visit the home. Some residents spoken with about the choice of meals did not know what was for lunch and did not know about any alternatives that were available. It was evident that when a member of staff went round to ask what people would like for lunch it was evident from their responses that this was an exercise that was being carried out for the inspectors benefit not the residents. The menus were available for inspection, however the days menus were not available for residents to see what was for lunch and tea. The menu was written on a menu board just before lunch. The inspector observed breakfast being served. Breakfast is served on a flexible basis from about 8.00 until 10.00am. Residents were offered a choice of cereals, toast and drinks. Lunch is the main meal of the day and consisted of sausage platt, chips, peas and gravy, followed by coconut sponge cake or walnut cake. It was noted that at least three residents who required assistance did not get it, as two members of staff were feeding other residents in the lounge. One member of staff was giving out medication and another was serving and clearing up. In some cases resident’s plates were taken away with them hardly eating any of the meal. Hot drinks were served during the meal, so when the dessert of cake was offered which was dry; residents had no drink left to help them get the cake down. The inspector requested that residents were offered another drink. At least two residents were being fed a pureed diet. This was all pureed together in one bowl and one resident refused to eat it and told the staff, “It’s awful”. Any food pureed (unless requested) should have each ingredient pureed separately to allow the resident to savor the different textures and flavours and to see the different colours of the food served. Teatime is a lighter meal and on the day of the inspection residents were served bacon sandwiches and ice cream. Again some residents were seen to be struggling to eat the sandwiches and no planning had been given to those on pureed diets apart from soup. This is not sufficient for residents’ as some had had little or no lunch. As there are several residents with dementia, some with high needs who require assistance and those requiring special diets, it is imperative that the Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 15 meals planned and the manner in which they are cooked and served are reviewed to ensure that residents receive a well balanced and nutritious diet and assistance given as required. There was no monitoring of what people had eaten at any meal observed. There was a large amount of wastage returned to the kitchen. It was observed that staff were going in and out of the kitchen without protective aprons. Staff should not have to keep going into the kitchen, as there is a serving hatch into dining room. The tables in the dining room are close together and it was noted that some residents were struggling to move freely around the tables and some residents were getting agitated. The plastic sheets used as tablecloths are unsightly and consideration needs to given to replacing these with more suitably table coverings. Woodlands Care GRP Ltd DS0000067718.V319997.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 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints system is in place ensuring residents and their supporters that any complaints and concerns will be listened two and appropriate action take. Not all staff have undertaken training in the protection of vulnerable adults, therefore potentially placing residents at risk of abuse. EVIDENCE: The complaints file was available for inspection. There have been no complaints made to the manager since the new owner took over. No complaints have been brought to the attention of the CSCI. The home has appropriate procedures in place for the protection of vulnerable adults. Some staff spoken with confirmed that they had not undertaken training in the protection of vulnerable adults which leaves both staff and residents in a vulnerable position and staff may not recognise the signs and symptoms of abuse in all of its forms. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 17 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 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing residents with a comfortable, clean and pleasant place to live. EVIDENCE: From a tour of the premises, it was evident that work is in progress to improve standards at the home. The main lounge had recently been decorated and several bedrooms had been decorated and had new fittings and furnishings. The home has recently had a new kitchen fitted. This is a much better for the cook to work in and to keep clean. More work planned and this will be carried out with the minimum of disruption to the residents. The bathroom and toilets are the next area to be addressed; this will be a big improvement, as the Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 18 bathrooms and toilets although clean and functional are looking tired and shabby. Several resident’s rooms were inspected, these were seen to be clean and tidy and residents had personalised their rooms with their own possessions brought from home. The main lounge is comfortable and tidy. The second lounge was cluttered with wheelchairs and zimmer frames and chairs that were not being used, suitably storage should be provided, the lounge should not be used for storage purposes. The home was clean and no offensive odours were apparent. Systems are in place to control the risk of infection, however the inspector had to remind staff about wearing aprons when serving food. The laundry is currently sited in the cellar away from food storage and food preparation areas and does not intrude on residents. There are plans to move the laundry upstairs which will make it easier for staff to get to. The outside area of the home is well maintained. The inspector appreciates that work is in progress which creates rubbish, however for the overall appearance of the home it would be beneficial if all the rubbish could be placed in a skip in one area instead of having rubbish at the rear of the home. There was an old carpet under the fire escape and a washer and other equipment at the front of the home. Rubbish would be better contained in one area. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 19 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 and 30 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home were insufficient and did not meet the needs of the residents. EVIDENCE: On the day of the inspection staffing levels were low. The home had twentyfour residents of which at least seven have a diagnosis of dementia, the recommended ratio for caring for people with a dementia related illness is one member of staff to every five residents therefore two members of staff were needed to provide care for those residents with dementia. Staff confirmed that at least three people needed the hoist to transfer them, but sometimes they had to manage on their own. Any transfer by using a sling to hoist a resident should have two people to assist, one to work the hoist and one to guide the resident to stop them swinging around. It was observed that several other residents had high dependency levels and needed assistance, and required a lot of staff attention. The residents would have benefited from four members of staff being on the floor providing care. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 20 In the absence of the manager, the senior carer was in charge of the home; this included answering the telephone, dealing with visitors, doctors etc and giving out the medication. The senior was also counted as working on the floor making the fourth member of staff, it was not possible for the senior to undertake two jobs. When speaking to staff one member had not had moving and handling training but was observed using the hoist and transferring residents, this is not only placing the resident at risk but also, placing the staff at risk of injury to herself. Not all staff had received training in the protection of vulnerable adults, therefore potentially placing residents at risk. One member of staff spoken with informed the inspector that some staff were currently undertaking training in dementia. As several residents had a diagnosis of dementia it is imperative that all staff receive training in caring for people with dementia as soon as possible. It may be beneficial if the cooks were included in the training as the way food is cooked and served plays an important part of caring for people with a dementia related illness. National Vocational Qualification (NVQ) training is ongoing with 59 of staff having achieved NVQ level 2. Information submitted to CSCI prior to the inspection indicated that 16 staff holds a current first aid certificate. Three staff files were looked. All contained a written application form, two references, Criminal Records Bureau checks (CRBs) and other forms of identification such as a copy of a birth certificate and marriage certificate was available in only file looked at. During discussion with one member of staff who has recently started to work at the home as the handy man, a CRB had not been applied for by the manager was asked to address this immediately and obtain a POVA First check. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was being well managed resulting in a consistent and reliable service for people using it. A satisfactory accounting system was in place, which protected residents interests. Not all staff had received relevant health and safety training, which could put residents at potential risk. EVIDENCE: The manager has the necessary skills and qualifications to manage the home. There have been a lot of changes in the last few months and the manager and her staff have coped well with these. The manager has a positive approach to Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 22 the changes and feels that they will be for the better for both residents and staff. The home had a satisfactory accounting system in place. Resident’s money is held individually and is securely stored. Any transactions are documented on individual balance sheets and receipts of transactions are kept. The home has systems in place for the auditing and monitoring the service. Regular checks are made of rooms, resident’s clothes, communal areas etc. The manager holds staff meetings and minutes of these were available. Residents and relatives meetings are not held and this may be an area for the manager to address. This would allow residents and relatives to voice their opinions and views on the how they find the home and the services provided. Consideration should be given to who leads the staff meeting as some staff may not be comfortable to discuss some things in front of the manager and the head carer. The manager confirmed that a new satisfaction questionnaire is being devised to allow residents to have their say. The results of any resident’s surveys should be published and made available to current and prospective residents, relatives and other interested parties. Staff supervision is an area that requires attention. The manager carries out ‘on the job’ supervision and annual appraisals, however the one-to-one supervision for all staff is not taking place at the required frequency. Formal supervision should cover all aspects of practice, the philosophy of care in the care home and staff development needs. Other staff including the cooks and domestic staff should be supervised as part of the normal management process on a continuous basis. The manager of the home must reiterate to all staff that fire doors must kept closed unless fitted with the appropriate door guards that are linked in to the main fire alarm system that will release them when the alarm is activated. All staff must be trained in moving and handling to ensure safe working practices. This should be up dated annually or covered on new staffs induction. All staff must be aware of infection control procedures and should not be going in and out of the kitchen without the necessary clothing or aprons. Information obtained prior to the inspection indicated that all the policies and procedures are currently under review. The information indicated the maintenance checks had been carried out for the gas, fire equipment and alarms, hoists, electrics and the lift. Certificates were available to verify this. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 23 All accidents, illness and injuries were suitably recorded and the CSCI informed as necessary. Woodlands Care GRP Ltd DS0000067718.V319997.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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 2 Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? New registration STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) 15(2)(b) Requirement You must ensure that where possible that the service user and their representative are consulted in the drawing up of the care plan and that the care plan is kept under review. You must ensure that the dignity of residents is maintained and personal care; specifically relating to the resident being shaved in the lounge is carried out in the privacy of the resident room or bathroom. You must ensure that the programme of activities arranged is appropriate to the needs of the service users with specific regard given to providing activities for people with dementia. You must ensure that all staff are trained in the protection of vulnerable adults to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. You must ensure that there are an adequate number of staff on duty to meets the needs of the DS0000067718.V319997.R01.S.doc Timescale for action 27/04/07 2 OP10 12 (4) (a) 02/03/07 3 OP12 16 (2) (n) 27/04/07 4 OP18 13 (6) 27/04/07 5 OP27 18 (1) (a) 27/04/07 Woodlands Care GRP Ltd Version 5.2 Page 26 6 OP28 7 OP29 8 9 OP36 OP38 residents. 18 (1) (c ) You must ensure that all staff (i) have received training appropriate to the work they are to undertake. Specifically training in: a) moving and handling b) protection of vulnerable adults. c) dementia care Schedule You must ensure that all staff 2 working at the home has a Regulation current Criminal Records Bureau 7,9, 19. check prior to commencing work 2(a) at the home. 18 (2) (a) You must ensure that all staff are appropriately supervised at regular intervals. Part 1V You must take adequate (4) (a) precaution against the risk of fire by ensuring that the fire doors are not wedged open or hooked back. 27/04/07 02/03/07 27/04/07 27/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The timing of when medication is given should be reviewed and unless specifically stated that medication is taken during the meal it may be better if staff waited until resident had finished their lunch. Residents who need assistance with eating their meals should be offered help in a discreet and sensitive manner. Residents receiving a pureed diet should have food presented in a manner, which is attractive and appealing in terms of texture, flavour and appearance. The rubbish from the front and rear of the home should be removed as soon as possible or contained in one area until it is practical to remove it. The lounge area should not be used for storage chairs that DS0000067718.V319997.R01.S.doc Version 5.2 Page 27 2 3 4 5 OP15 OP15 OP19 OP22 Woodlands Care GRP Ltd are no longer required and wheelchairs, suitable storage areas should be provided. Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Woodlands Care GRP Ltd DS0000067718.V319997.R01.S.doc Version 5.2 Page 29 - 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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