Inspection on 22/07/08 for Woodlands Care Home

This inspection was carried out on 22nd July 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodlands Care Home 09/03/10

Woodlands Care Home 10/02/10

Woodlands Care Home 16/02/09

Woodlands Care Home 20/08/07

Woodlands Care Home 30/09/06

Woodlands Care Home 06/03/06

Woodlands Care Home 01/11/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Woodlands Care Home Fairfield Road Broadstairs Kent CT10 2JU Lead Inspector Penny McMullan Unannounced Inspection 09:30 22 and 23rd July 2008 nd 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 Home DS0000065784.V367761.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 Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Care Home Address Fairfield Road Broadstairs Kent CT10 2JU 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) 01843 860998 01843 862865 www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mrs Andrea Callow Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 33. Date of last inspection 20th August 2007 Brief Description of the Service: Woodlands Care Home is a purpose built two-storey building set in gardens next to Fairfield Manor Care Centre, both of which are owned by the same company. Ashbourne (Eton) Ltd is the registered company, which is a subsidiary of Southern Cross Healthcare. Accommodation comprises of thirty bedrooms that are all currently used as singles, but this number includes three larger rooms that can be used as doubles. All bedrooms have en-suite toilet facilities. There is a lift to the first floor and ample bathroom and toilet facilities. Communal areas consist of the main lounge, a very small lounge and dining room. There is a well-kept garden to the side and patio area at the front of the building for residents’ use. Shared parking facilities are available to the front and the home is located in a residential area on the outskirts of Broadstairs. The home offers personal and nursing care. There is always at least one registered nurse on duty, with a team of carers and ancillary staff that deal with cooking, cleaning, laundry, administration and maintenance. The fees for support from the home are set during the assessment period and are very specific to the needs of the individual, depending on the level of support required and the staffing numbers provided. At the time of this inspection the fees are not available, please contact the home direct for further information. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 5 Woodlands Care Home DS0000065784.V367761.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 1 star. This means that the people who use the service experience adequate quality outcomes. This key inspection was carried out over a period of time and concluded with an unannounced visit to the home on 22nd and 23rd July between 9.30 am and 4.30 pm. Residents and staff were spoken to. Observations included interactions between residents and staff. Surveys were sent to the home to distribute to residents, staff and professionals. Feedback from the people who use the service and relatives is positive in some areas however all indicated that at times there is not enough staff on duty. Staff also say there are shortages of staff and further comments have been included in this report. No professional surveys were received back. Various records were viewed during the inspection and a partial tour of the home was made, including the communal areas and some bedrooms. The Registered Manager was not available at the time of this inspection and the Deputy Manager assisted throughout the inspection and was supported by the Registered Manager of Fairfield Manor. At the previous inspection, one statutory requirement to review staffing levels was made. This was because the people living at the home appeared to have greater support needs than the number of staff provided could cope with. We requested evidence that this review had taken place, but none could be provided, so the requirement, and therefore the Regulation have not been complied with. Other serious shortfalls with regard to recruitment have also been identified during this visit. This means that the CSCI will issue a warning letter and a statutory requirement notice may be issued to the provider of the service. We issued an immediate requirement with regard to the sluicing facilities, as they had been out of action for a long period of time. The person in charge of the home could not show us, or tell us what the plans were to mend this facility. Their absence means that people are at risk from cross infection. Further detailed information can be found in this report concerning these issues. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Pre admission assessments forms need to be completed fully so that prospective residents support requirements are fully known. This is to make sure they will have their needs met. Although medicine management is good, the storage room needs to be organised better and tidied up. Staff could benefit from having access to medicine training updates so they feel confident and keep up to date. The home needs to have local policies and procedures and information to inform staff so a common approach is followed. All staff need to have safeguarding adults training and have a working knowledge of safeguarding protocols to ensure that residents are protected from abuse. The staffing levels must be reviewed, and be kept under regular review. This is to make sure that there is sufficient staff on duty to meet residents needs. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 8 Improvements are required when recruiting staff to ensure that residents are receiving care from appropriately vetted staff. The training programme needs to be improved to ensure that all staff receive the appropriate training and there are records that staff on their induction training have the competencies to do their job well. The Registered Provider must ensure staff left in charge of the home on a daily basis have the right knowledge and experience to effectively manage the home and that all records are accessible and available for inspection. Although there have been plans to add a conservatory to the home this has been suggested since the previous three inspections but there is no indication that this will be completed. This would give residents additional communal space for leisure and activities. When asked if they receive the care and support they need one resident said: ‘When someone who understands English well enough is around’. ‘There are many overseas members of staff at the home and often it is difficult to understand them as they have strong accents/their command of English is limited and sometimes I wonder if they fully understand when we speak to them’. ‘All night staff are from overseas, they often communicate to themselves in their own languages - difficult for hard of hearing to understand’. The Deputy Manager says that staff has been spoken to and this issue has been addressed, however there is no written record of this taking place. Resident comments: ‘Sometimes the home is under staffed’. ‘Yes they are short of staff and the carers work their ‘little socks off’, they are always there day and night.’ ‘Sometimes I have to wait for staff to come when I call – sometimes they are short – if I do have to wait they usually come and tell me’. ‘Apart from the staffing levels there are no improvements necessary for me’. Staff comment: ‘Invest money to increase staff levels, improve the homes facilities, such as increase the lounge areas’. ‘Carers are working in excess of 45 hours but the organisation will not increase staffing levels due to the cost. The company is not adhering to health and safety regulations and staff and services users are left to put up with things until someone complains to outside agencies. The Deputy Manager says that some staff have worked additional hours to cover but new staff have now been recruited. The issue on health and safety has now been resolved. Please contact the provider for advice of actions taken in response to this inspection. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 9 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 Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 10 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 Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 11 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 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are procedures in place to ensure that a care needs assessment is carried out for all prospective service users, however the lack of recording such detailed information may result in the needs of the people not being fully met. EVIDENCE: The Registered Manager or Deputy carries out the care needs assessments for prospective service users. Three residents files were viewed and all contained assessments, however one was not fully completed or dated and signed. There are joint assessments and details of hospital discharges and care plans from the placing authority in place. A recent safeguarding alert highlighted improvement is required when admitting residents to ensure that the care staff have the skills to meet the resident’s individual identified needs. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 12 Service user comment: ‘I visited the home with a friend at meal time - we were shown around with the former Care Manager she spent a good half hour plus with us. We were given a leaflet etc.’ There is evidence that healthcare professionals are supporting residents when receiving intermediate care and rehabilitation. At the time of the inspection a resident was observed receiving support from the visiting physiotherapist who was discussing the individual plan with the carer. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use the service cannot be sure their personal care and health needs will be fully met. The residents receive their medicines as prescribed. The healthcare needs of the residents are met by accessing healthcare professionals when needed. Improvements are required to ensure that dignity is upheld at all times. EVIDENCE: We looked at three care plans, which contained details of all aspects of health care needs. These included risk assessments identifying high dependency needs such as nutrition, skin integrity, tissue viability, risk of falls, communication and when required the use of body maps. The plans had been reviewed monthly and there is evidence of residents’ involvement in the plans. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 14 The recent safeguarding issue raises concerns with regard to health and welfare of service users. The plans indicate that all care needs are recorded and risk assessments identify what needs to be done to minimise the risk in all aspects of care. However the issues raised in the current adult protection alert indicate that there may be insufficient numbers of trained staff on duty to ensure the care plans are being implemented and individual care needs are being met. There are eight new carers who commenced their duties in June of this year and who are currently completing their induction programme. This means that they will require additional support to ensure they have the competencies to meet residents’ needs. Health care needs are clearly outlined in the plans and the nursing staff reviews all records on a monthly basis. There is also evidence of relative involvement in the reviews. There is equipment available to promote the tissue viability and protection or treatment of pressure sores, however there were concerns raised in the recent safeguarding alert. The detailed information and safe practice of work identified in the care plan must be carried out in the care practice to minimise the risk of pressure sores. The home has corporate policies covering all aspects of medicine management. There are no additions to these policies for local variation in the procedures. There is no policy on use of equipment, although the manufacturer’s instruction leaflets might be in the medicine storage room. A recent copy of the BNF (March 2008) was available. Records around medicine management and hand written changes on the MAR were signed. Further detailed notes were available. There was documented evidence for doctor, dentist, dietician and optician visits. There were no guidelines for the use of medicines prescribed on a ‘when required’ basis in the individual care plans. The administration procedure followed good practice. The staff are registered nurses. The last update training they had was in 2005 according to staff we spoke to. The medicine storage room is well equipped and provides the right conditions for storage of medicines but it was a storage room rather than a workflow room. The medicines for disposal were in a large open container. Medicine removed for disposal are recorded and then added to this container, which is removed by a disposal company when full. This container is not in a locked cupboard. There are concerns when the RGN is carrying out the administration of medication round in the morning when it can take 2 to 3 hours to complete. There is only one RGN on duty and this puts residents at risk of not having their nursing care needs met whilst the nurse is focused on the administration of the medication. The home needs to ensure that residents also receive their medication at the prescribed time. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 15 Staff were observed talking to the residents in a respectful manner and encouraging and supporting them well. Carers assisting service users to eat in the dining room demonstrated their understanding and patience to ensure the people who use the service received a pleasant meal. Two people who use the service confirmed that the carers knock before entering their rooms and they feel respected by the care staff. Dignity could be improved by ensuring the people who use the service are not taken to the toilet at specific times of the day. This indicates that the routines in the home are task led and not in the best interests of the people who use the service. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 16 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. Residents are encouraged to participate in the daily activity programme. Residents are supported to make choices, enabling them to have some control over their daily lives. The home provides nutritious and varied meals for the residents. EVIDENCE: The people who use the service talked about the activities being provided and their choice as to whether they take part. One resident said how much she enjoyed going to the local supermarket and was looking forward to helping with the fete on Saturday. They are two dedicated activity organisers who plan and record the activities provided. A poster outlining the events is on the notice board. There are a variety of activities available, from one to one sessions, outings, board games and bingo. The people who are unable to leave their rooms are visited on a one to one basis to provide some social Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 17 interaction. A resident is also supported to keep in contact with his relative through email. Resident comment: ‘Being disabled there is very few activities I can take part in - play dominos and other table games’. Relative comment: ‘My relative sometimes joins in if he likes it’. Visitors spoken to at the time of the inspection confirm they are always made welcome. They are offered a cup of tea and can stay for a meal with their relative if they wish. Residents are able to receive their visitors in the privacy of their own rooms or in the communal areas. Resident comment: ‘The staff are always polite and they always ask if my visitors want a cup of tea and they never mind what time the visitors call’. The people who use the service say they feel they have some choice over their daily lives and can choose what they wish to do. They gave examples of how they choose what to wear, where to sit and their preferences about going to bed. The home has set routines in place and this may restrict choice for the people who use the service. Choice may also be compromised it there are not enough staff on duty. Feedback from residents, staff and relatives indicates that the food is good and they receive good portions. The food looked appetising and well presented. There is a four week menu in place and the people who use the service are offered three choices a day. The cook demonstrated her awareness of nutrition and special dietary requirements. She ensures that homemade cakes are provided for tea and drinks are readily available throughout the day. There is a large dining room and staff were observed assisting the people who use the service to enjoy their meals. Woodlands Care Home DS0000065784.V367761.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints procedure in place to ensure residents are confident their complaints would be listened to. Improvements are required to ensure that the people who use the service are protected from abuse. EVIDENCE: The home has a complaints procedure in place and the people who use the service say they would complain to the manager if they had any concerns. There is a complaints log in place and issues were seen to be recorded and actioned. Service user comment: ‘If I had a complaint I would speak to the Registered Manager’. Since the previous inspection there has been safeguarding alerts in the home. It was highlighted that recruitment procedures indicated an area of weakness and that protection procedures were not sufficiently robust to safeguard residents. The recruitment practices of the home have not improved and a requirement will be issued in this report. Please refer to Standard 29. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 19 Some Protection of Vulnerable Adult Training has been provided for staff, however there remain a total of eleven members of staff who require this training. The home needs to ensure that all staff are trained to protect service users from harm and ensure that residents are receiving care from appropriately vetted staff. Two members of staff spoken to at the time of the inspection did not demonstrate they had an awareness of adult protection procedures. A recommendation will be made in this report. Woodlands Care Home DS0000065784.V367761.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, 20 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean, comfortable and maintained to a good standard, however improvements are required to sluicing facilities to minimise the risk of infection. EVIDENCE: The home employs a maintenance person and there is a planned programme of routine maintenance in the home. The gardens are well kept and accessible and residents were seen outside enjoying the sunshine. There seems to be some delay in repairs when authorisation is required from head office, a water problem and leaking tap were referred to the head office on 26 June and the repair was not schedule to be started until 21 July 2008. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 21 During the last three inspections it has been indicated that the organisation intends to add a conservatory that would provide additional space for seating and activities. The Deputy Manager says he is aware of the plans but no further action has been taken at this time. A recommendation will be brought forward in this report. There are mixed comments with regard to the cleanliness of the home from the postal surveys sent to residents as follows: ‘the lounge does leave a little to be desired. An addition of air fresheners would help. I appreciate that caring for so many people is difficult but this could be made a little more pleasant’. ‘The home havent got the time and staff to keep it that way’. ‘Dusting not very regular - vacuuming very good’. Another resident comment: ‘The home is kept lovely and clean’. At the time of the inspection the home was clean and tidy and had a pleasant smell throughout. Alcohol hand scrub is available throughout the building. The two sluicing facilities in the home are out of order and have been for some time. An immediate requirement was made to contact the Environmental Health Officer to discuss suitable infection control measures to implement whilst the sluices remain out of order. The Deputy Manager spoke to the Environmental Officer who advised him to contact the Health Protection Agency. The home must tell the Commission the outcome and what has been put in place to minimise the risk of infection. Although the majority of staff have attended infection control training there is still eleven staff who require training. Woodlands Care Home DS0000065784.V367761.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are not enough staff on duty at all times with the necessary skills and knowledge to meet the needs of the residents. Residents are left at risk because of poor recruitment practices and are receiving care from staff who have not been appropriately vetted. Improvements are required in the training program to ensure that staff have the skills to meet service users needs. EVIDENCE: On the day of the inspection in the afternoon there was one RGN on duty, two experienced care staff on duty and one inductee to cover 29 service users with high dependent needs. There was one additional person coming on duty at 4pm. Staffing rotas over a two-week period show that the level of care staff provided can vary from a maximum of six in the morning and five in the afternoon to a minimum of five in the morning and on two occasions three in the afternoon. There were also the two activities organisers, a laundry assistant, two domestics, the cook, one kitchen assistant, an administrator and maintenance person. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 23 In discussion with the Deputy Manager and care staff it appears that all of the residents in the home are high dependency with a total of 25 requiring more than one carer to assist them and 15 require assistance when eating. With this high dependency and the administration of medication taking two to three hours, together with the number of service users who are nursed in bed, staffing levels do not appear to be in sufficient numbers to meet the residents’ needs. A review of staffing levels was a requirement at the previous inspection and there is no evidence to indicate that this had been complied with. We have received feedback from service users, relatives, and staff that there is insufficient staffing levels in the home. There have been eight new carers since June 2008 and this is having an impact on the delivery of care as more pressure is put on established care staff to support carers through the induction training. Therefore there is a large proportion of staff who may not have the experience to meet all residents needs. A carer comments that when new staff are required to complete the moving and handling training they are just taken off shift leaving a shortage of staff on the floor to meet service users needs as no cover is provided. Staff comments: ‘There is not always enough staff on duty and everything is in a rush’. ‘We are often short staffed’. ‘ We always have a shortage of staff’. ‘We are always short of staff – weekends are the worst’. ‘We are short staffed especially at weekends this is due to the same people going sick – we have a lot of high needs here and it is difficult to make sure everything is done’. Resident comment: ‘There is always someone to answer my calls though not at once’. ‘Generally speaking we find the staff to be caring and very good. Given the amount of residents needing high dependency care, we do sometimes wonder if ratio of staff to patients is adequate, especially at night’. As the requirement from the last inspection has not been compiled with the home has been issued with a warning letter and a Statutory Requirement Notice may be issued. The notice is part of CSCI’s enforcement pathway and it will tell the home they must review staffing levels to demonstrate that sufficient staff are available at all times to meet service users needs. Our timescale for this work to be completed by is 22nd August 2008. The Commission will revisit this area to ensure that this regulation has been complied with. The Deputy Manager says that nine carers currently have NVQ 2 or above and that there are eight new recruits who will be signing on the course in the next six weeks. There was no evidence at the time of the inspection to confirm this information although one carer on her induction stated that she would be commencing the course in the next few weeks. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 24 Staff are working in the home without being appropriately vetted. Three staff files were seen and two application forms show gaps in their employment history and there was no evidence that this has been discussed during interview or recorded. In one case there were two satisfactory character references on file, but this did not include one from the previous employer. Another file only contained one satisfactory reference. POVA first checks have been completed and a copy of the Criminal Records Bureau application form are on file, however at the time of the inspection these had not been received. The Deputy Manager says that the carers concerned are still working under supervision. A requirement will be made in this report and this failure to comply with Regulations may form part of the Statutory Requirement Notice as previously mentioned in this report. Training records indicate that there is an ongoing programme in place. Information from the training matrix indicates that there are shortfalls in the provision of fire safety, food hygiene, moving and handling, health and safety and infection control. At the time of the inspection the Deputy Manager could not indicate what future courses have been booked to address these shortfalls. There are several new members of staff who are completing their induction and although an induction programme is in place there was no evidence provided at the time of inspection to confirm that competencies have been achieved. The home needs to evidence better that new recruits have completed their induction and have the skills and competences to meet service user needs. There have been eight new members of staff since June requiring induction. A requirement has been made in this report. Woodlands Care Home DS0000065784.V367761.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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The effective management of the home is at risk due to the lack of arrangements to ensure that staff have the knowledge and experience to run the home on a daily basis. Health and Safety is promoted in the home to provide residents and staff with a safe environment. EVIDENCE: Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 26 The Registered Manager was not available at the time of this inspection. The Deputy Manager assisted with the inspection supported by the Registered Manager from Fairfield Manor (sister home next door). In the absence of the Registered Manager the Deputy has been assigned as being responsible for the day-to-day running of the home. The Deputy Manager told us that when the Registered Manager is on duty he only has approximately 16 hours of his time allocated to managerial duties and the rest of contracted hours are for RGN cover providing direct nursing care. He therefore is not fully involved in the total management of the home and struggled to find some of the documents required for the inspection. The Deputy Manager provided as much of the information that he was aware of however there were still records that he could not produce for inspection. A requirement to ensure that all records are available for inspection will be made in this report. In the absence of the Registered Manager the Deputy requested authorisation from head office for additional staff to assist with the management of the home. There was no response to this request. The Deputy Manager needs to be fully trained in the managerial duties of the home to ensure he has the knowledge and skills to manage the home. In the absence of the Registered Manager and with no additional support from the organisation or additional staff on duty there are concerns with regard to the effective management of the home. There was some evidence at the time of the inspection that quality assurance is carried out in the home. The last regulation 26 visit by the provider was completed in June and monthly audits on all aspects of the home are in place. Residents’ meetings are held every three months and the last meeting was in April 2008. The Deputy Manager was unable to provide evidence of a quality assurance programme and service users spoken to say they have never received a questionnaire asking them about the services. Residents did say that when the Registered Manager is on duty she visits them on a daily basis. The report from the previous inspection indicates that a yearly quality assurance assessment is carried out and the AQAA states that advocacy services are in place; therefore no requirement or recommendation will be made in this report. Previous inspections have confirmed that procedures are in place to ensure that any monies held on behalf of residents are appropriately stored and records maintained of all transactions made on their behalf. Supervision is now in place and appraisals are undertaken for all staff. The Deputy Manager says that he only has a couple more to do before he has completed them. Supervision records are in place and on the whole are up to date, however due to pressure of work and providing direct care sometimes the timescales are not always achieved. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 27 Although there are some shortfalls in the mandatory training it is being provided and there is also an induction programme in place. Risk assessments are in place, the fire book is in good order and water temperatures are recorded. The home needs to ensure that all staff are involved in the fire drills to ensure they know the procedures in case of a fire. All service users have a fire evacuation plan. The home has informed us that all the relevant checks and inspection of equipment and system have been undertaken. An accident book is maintained, however the accidents were not endorsed with the Registered Manager or person in charge signature. Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 3 2 X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X 3 Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 29 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. OP9 Standard Regulation 13(2) Requirement The Registered Provider to ensure medicine removed for disposal is kept in lockable cupboards to minimise risk of misappropriation. The Registered Provider to make sure that there are enough nursing staff and other suitably qualified, competent care staff on duty at all times, taking account of the numbers and assessed needs of residents and the layout of the building. In that you have failed to carry out a review of staffing levels to be carried out and any identified adjustments made to staff rotas, with improvements implemented and evidence submitted. This requirement had a first timescale for action of 15/10/07, which has not been complied with. 3. OP29 19 Sch 2 (3)(6) The Registered Provider to ensure that a) two written references including, where applicable, a reference Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 30 Timescale for action 30/08/08 2. OP27 18(a) 29/08/08 29/08/08 4. OP30 12,18(c ) (i) 5. OP31 9 (2)(b) (i) 6. OP31 17(3)(b) relating to the person’s last period of employment, and b) application forms are completed and a full employment history, together with a satisfactory written explanation if any gaps in employment To ensure that all staff receive 30/08/08 appropriate training and the induction programme for staff is recorded in detail to confirm that staff have the competencies to meet residents needs The Registered Provider to 30/08/08 ensure that in the absence of the Registered Manager, the Deputy Manager has the experience and full knowledge of managerial duties to run the home on a daily basis. The Registered Provider to 30/08/08 ensure that all records are available for inspection RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP2 OP9 Good Practice Recommendations To ensure that all assessments of needs are completed with full information, signed and dated by the Assessor. Medicine prescribed on a ‘when required’ basis would benefit from a guideline in the care plan which give criteria to use as to when to administer this medicine. This would ensure a common approach in the use of this medicine. To have a general clear out of the medicine storage area DS0000065784.V367761.R01.S.doc Version 5.2 Page 31 3. OP9 Woodlands Care Home 4. 5. OP18 OP20 to make it a good working area to allow clutter free working environment To ensure that all staff receive protection of vulnerable adult training and have a clear understanding in this area That additional communal space is provided to ensure residents have enough communal seating and recreational space, other than in their bedrooms, to support the provision of a selection of activities, to meet individual needs. (This relates to the planned conservatory identified at the last 3 inspections that has been put on hold). Woodlands Care Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Home DS0000065784.V367761.R01.S.doc Version 5.2 Page 33 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!