Inspection on 28/02/07 for Woodlands (Colchester) Ltd

This inspection was carried out on 28th February 2007.

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 (Colchester) Ltd 27/02/09

Woodlands (Colchester) Ltd 23/02/06

Woodlands (Colchester) Ltd 12/10/05

Woodlands (Colchester) Ltd 23/03/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Woodlands (Colchester) Ltd 76 Lexden Road Colchester Essex CO3 3SP Lead Inspector Pauline Dean Unannounced Inspection 28th February 2007 09:35 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 (Colchester) Ltd DS0000061910.V331288.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 (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands (Colchester) Ltd Address 76 Lexden Road Colchester Essex CO3 3SP 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) 01206 571200 01206 505450 sam@woodlandsrh.freeserve.co.uk Woodlands (Colchester) Limited Mrs Julie Wells Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Twenty three female service users, aged 65 years and over, who require care by reason of old age only 23rd February 2006 Date of last inspection Brief Description of the Service: Woodlands is located within the Lexden area of Colchester, an established residential area to the west of the town centre. There is approximately a tenminute walk between the home and the town centre. Public transport, passing to the front of the home, is frequent. The nearest train station is Colchester Town, approximately half a mile distant. Fees are £450 - £585 per week. Hairdressing, chiropody, toiletries and newspapers and magazines are all charged at cost. The early 1900’s property was a former large family dwelling and has been developed to present the current accommodation. The home is solely for women. The accommodation is arranged on two floors, the upper floor is accessed via a passenger lift. Single and shared bedrooms are available and there are various communal rooms including a lounge, dining room, small conservatory/hairdressing salon and a large conservatory. There is a rear garden incorporating a sun terrace and lawn. The front of the property, enclosed by trees and shrubs, includes parking and seating areas. The garden also extends along one side of the home. Mrs Julie Wells is the Registered Manager. Miss Samantha Racey, the Responsible Individual of the company and Mr Chris Graham director of the care home are also involved in the day to day running of the home. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, covering the key National Minimum Standards, took into consideration all recent records relating to the service, including information sent to the Commission by the Providers. A record of inspection was collated prior and during the inspection process. It also included a site visit to the home on 28/02/07, which lasted 10 hours. At this visit, the inspector was able to speak with residents, Mrs Julie Wells, the registered manager, a healthcare professional and staff. A tour of premises was completed and there was observation of care practice and the sampling of records. Where possible, the site visits focussed on the experience of a sample of three residents, a process known as case tracking. Of the twenty-four National Minimum Standards inspected on this occasion, one was not applicable, twenty-one were met and two were nearly met. One was a repeat requirement from the last inspection. It is acknowledged that staff and management have worked hard to address the shortfalls identified in previous reports, and overall their efforts have been fruitful. The outstanding requirements relate to staff recruitment practices and management care qualifications. What the service does well: As at the last inspection Woodlands presents as an attractive, well maintained care home. Decoration and maintenance are ongoing, with particular attention paid to the communal areas of the home. With the addition of the large conservatory, this accommodation is further enhanced. Survey work completed praised the management and staff of the home. Comments such as “….… has always praised Woodlands” and we “ have never had cause for complaints and I don’t think we ever will,” were found in the Comment Cards completed by relatives and visitors. Two residents spoken to at the site visit were also very positive with regard to the care they receive from both management and staff. Nutrition and the food once again are given high consideration at Woodlands. Both catering staff and management ensure that residents have meals to their liking and recent quality assurance work has promoted changes to the menu planning. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Documentation ensures that residents move into the home knowing that their needs will be met. Woodlands care home does not offer intermediate care. EVIDENCE: There have been some changes in the resident group since the last inspection. Care planning documentation was sampled and case tracking took place for three residents. Within one file a Needs Assessment and a Nursing Needs Assessment were found for a recent admission to the home and this evidenced that a detailed full initial assessment process had been followed and all aspects of care had been considered. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 9 Woodlands care home does not offer intermediate care. £585.00 per week. Fees are £450.00 to Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning documents fully detailed the action to be taken and by whom and regular reviews of care plans took place. Overall medication storage and record keeping offered protection to residents. Residents are treated with respect and dignity and are actively supported to maintain control of their care and health needs, as appropriate. EVIDENCE: A plan of care had been developed for all three of the residents involved in this case tracking exercise. For the most recent admission an initial care plan was completed and a monthly review had been completed in February 2007. As with the other two care plans sampled objectives, strategy, responsibility, timescale and review were covered. Following the site visit examples of the development of these documents had been sent to the Commission and these Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 11 clearly detailed the action that needs to be taken to ensure that the resident’s care needs are met. One resident spoken to at the site visit who was not part of the case tracking exercise praised the home for the care they received and was aware of their care plan and the contents of this plan. Prior to this site visit and writing this report, the Commission conducted a survey of the views of relatives and visitors to the home. A total of twelve responses were received from family and friends. All were very positive with regard to the care of their relative/friend and comments such as “My mother has had the best of care” and “She is very happy there.” were made. Commission survey forms were left with the home on the day of the site visit. At the time of writing this report, they have not been returned, but on receipt will be considered in future inspections. A health care professional visiting the home on the day of the site visit was interviewed. They said that they had “observed good practice” in the home and their first impressions were that the home was “very good and homely.” Within care plans there was evidence of in put from health care professionals. Record keeping evidenced when visits and appointments had taken place and any changes to care had been considered in monthly reviews, with the care plan updated. This was evidenced in the care plans considered as part of the case tracking sample. One resident spoken to confirmed that as and when they needed to see their GP, care staff would initiate this. They also said that on moving to the home they had had to change doctors and this too had been arranged by the home. Medication administration, storage and record keeping for medication in current use was sampled and inspected. This was well managed. Medication Administration Records (MAR) sheets were accurate and corresponded with medication administered and held in the home. Records were seen of medication entering the home, leaving the home and disposed of. At the site visit the practice of storing medicines for return to the pharmacist in the small lounge/hairdressing salon was considered. It was noted that the storage bags were in the room and not in a secure cupboard. Mrs Wells said that normally medication for return was collected early in the day. Initially it was thought that the bags contained medication for return to the pharmacist, but it is now understood that these storage bags contained medication packaging only. It is therefore acknowledged that residents were not placed at risk on this occasion, however the home has reconsidered their practice and confirmed that medication return bags will be held in locked cupboard. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 12 During the site visit, residents were seen to be treated with respect and dignity. Staff spoke respectfully with residents and they were seen to knock on resident’s bedroom doors and wait until they were granted entry. Since the last inspection a sink unit and equipment has been fitted in a small lounge off the dining room and a hairdressing salon has been created. The practice of using a resident’s bedroom has ceased. Mrs Wells said that the salon had proved popular and was used regularly by hairdressers who come into the home. Woodlands (Colchester) Ltd DS0000061910.V331288.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and preferences were taken into account in the organisation of daily schedules. Residents were supported to maintain contact with family and friends. Residents were able to exercise choice and control over their lives. Mealtimes were a positive experience for residents. EVIDENCE: As at the last inspection Mrs Wells spoke of wishing to promote in-house activities and entertainment in the home. A flip-chart programme of activities has been created and was on display in the main lounge. On the day of the site visit, a guitarist entertained the residents in the lounge in the afternoon. The majority of residents were present and enjoyed singing along with the entertainer. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 14 A variety of in-house activities were listed in the programme of activities in the home. Mrs Wells said that residents are encouraged to participate, but the choice as to whether they wished to attend is their own choice. Activities listed included crosswords, reminiscent cards, quizzes, beanbag exercises, musical bingo, musical entertainment and dice games. Within the comment cards received by the Commission for Social Care Inspection (CSCI) a comment had been made as to the “lack of stimulation.” It was said that “Rotas of activities are displayed, but very rarely is this list adhered to.” Mrs Wells said that whilst this aspect of care is considered in the home, she acknowledged that further promotion of social activities and local outings could be promoted. A recent care workers meeting had highlighted the need for care staff to ensure that there is an activity on offer each afternoon and physical exercise should be offered at least once a week. Residents who would like to go for a short walk should also be enabled to do so as they wish. Following this site visit, the management of the home have confirmed that a rota of activities is offered and records are kept of these activities and those attending the activities. Unfortunately these records were not found on the day of the inspection, but they will be reviewed at future inspections. During the site visit, visitors were seen to come and go during the day. Some visitors met with their relative in their room and others visited their relative in the main lounge area. One resident confirmed that visitors are made most welcome, with refreshments offered and they may see them in their room in private or in the main lounge as they wish. An inventory record was seen of items, which had been brought into the home. One resident spoken to confirmed that they had been able to bring in small pieces of furniture, photographs and ornaments and a television. On the site visit, the inspector had an opportunity to see residents having breakfast and lunch. Breakfast time was flexible with residents having breakfast as they awoke. The cook on duty said that currently the home has a take up of over 50 regularly having a cooked breakfast. Both residents and the cook spoke of a variety of food and meals offered. The home has recently revised and reviewed their menu planning and there is now a nine-week rotation menu for lunchtime meals, with the home currently continuing with a fourteen-week rotation menu for teatime meals. At lunchtime two choices are normally offered for the main course with at least two dessert options. Teatime menus offered both a hot and cold dish with homemade cakes and desserts. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 15 On the day of the site visit, Woodlands Care Home had twenty-two residents of which two are diabetics. The cook outlined how these residents were accommodated and they spoke of how they ensure that they as with other residents have a good balanced diet. Lunchtime arrangements were observed on the day of the site visit. The dining room arrangements and the presentation of the meals were well managed and attractively presented. The inspector sampled the roast lunch served and it was found to be hot, with a variety of well-cooked vegetables, served with a hot dessert. The inspector was informed by the cook that the two cooks employed in the home are to attend additional food hygiene training - a Food Safety Awareness day – Level 2 on Food Safety in the next few weeks. From speaking to the cook on duty, the inspector formed the opinion that they have a good understanding of the catering needs of the residents and promoted good catering practices in the home. They had responsibility for ordering the food supplies using both local and national suppliers for fresh, frozen and dried foods. Food supplies seen were in good supply and were found in the kitchen and outside storage. Catering staff completed records of fridge and freezer temperature checks and recommendations were made regarding the identification of each fridge/freezer at the piece of equipment and in the record keeping. Woodlands (Colchester) Ltd DS0000061910.V331288.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 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, residents were well treated and listened to, with robust complaints and adult protection procedures in place. EVIDENCE: At the site visit a complaints procedure was seen on display. This made reference to the Commission for Social Care Inspection (CSCI) and stated that the complainant may raise a complaint with the Commission with the expectation that it will be investigated. This was discussed with Mrs Wells and it was agreed that this policy would be reviewed and revised to fully detail the Commission’s role as a regulator and not as an investigator of complaints. The Commission has received a copy of this revised complaints procedure and this now meets requirements. Prior to this site visit, the Commission had been made aware by the home of a complaint raised by the local hospital and the lack of an escort for a resident to attend an appointment at the Eye Clinic. The home had undertaken a detailed review of the events and whilst it was acknowledged that no escort had been available in the circumstances it was felt that the home had complied with the clinic’s wishes. Following several telephone communications with the Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 17 hospital, a detailed written response had been sent to the hospital. Mrs Wells said that this matter is now considered closed. At the site visit, Woodlands Care Home had a Policy on Protection. Some shortfalls and amendments were noted at the visit and subsequently a revised policy entitled – ‘Policy on Protection of Service Users’ has been developed. This document is more comprehensive, detailing action taken should a referral be made and preventative measures in place e.g. staff recruitment practices and staff training. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, the home provides a safe, well-maintained environment that is accessible to residents, homely and meets individual needs. EVIDENCE: On the site visit a tour of the premises was conducted. Not all of the bedroom accommodation was seen. The home was warm, light and well decorated. New carpets have been fitted in communal areas and some corridors. Covers for radiators and hot water pipes have been fitted, as have thermostatic valves on hot water taps accessed by residents. It was noted however, that some notices stating ‘Very hot’ remain in place. This was discussed with Mrs Wells and it was felt that this could lead to confusion and a misunderstanding. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 19 The new conservatory at the rear of the property has been brought into use. This followed confirmation of planning permission and visits from the fire service and environmental health that confirmed compliance with statutory legislation. Unfortunately problems had been found in the base of the conservatory and the carpet had been removed to allow the base to dry out. This had resulted in residents being unable to use this facility. Mrs Wells said that as soon as the room had dried out and the problem had been resolved, new carpet was to be fitted and residents will be able to return to using the facility. One resident said that they had enjoyed using the room and acknowledged that it had aided access to the sun terrace area and the rear garden. Bedroom accommodation was sampled and seen on the site visit. One resident was happy to show the inspector their room and whilst it was one of the smaller rooms they said that they were very pleased with the room. Pictures and shelving had been fitted to accommodate their personal items and some changes had been made to accommodate some items of furniture. Some of the changes did appear to create restricted access to the room however. This was raised with Mrs Wells and whilst she was not initially aware of these changes on seeing them she did acknowledge that changes are required to improve access and facilities in the room. Consideration has been given to the provision of lockable storage space. Mrs Wells said that this has been managed through discussion with individual residents. She said that residents had been asked if they would like a lockable storage space for medication, money and valuables and the majority had decided that they did not need this facility. An example of this was seen in the documentation of a care plan of a recent admission to the home. Mrs Wells was advised of the need to continually review this situation to ensure that residents have this provision as they wish in the future. Thermostatic controls have been fitted on all hot water taps accessed by residents. These were noted on the tour of the premises. Records are also kept of hot water checks. Radiator covers and covers for hot water piping has been fitted. Thermostatic controls fitted enable residents to control the temperature in their rooms. Since the last inspection, some building work has taken place in the home’s laundry room. New racking has been installed to accommodate a smaller water tank and booster pump for laundry purposes. Mrs Wells said that this had been found to be needed following consultation on the Water Supply (Water Fittings) Regulations 1999. There are two washers and two dryers in the laundry. Laundry is completed during the day by care staff with ironing completed by night care staff. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 20 A new sluice is to be fitted in a newly Tiling and flooring has been completed installation of the sluice. Mrs Wells environmental health to ensure that the created sluice room on the first floor. and the home is now waiting for the is aware of the need to liaise with fitting meets requirements. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Staff were roistered in sufficient numbers to keep residents users safe and address their basic needs. The home has an experienced and dedicated staff team and residents are protected by the home’s recruitment practices and training programme. EVIDENCE: From discussion with Mrs Wells and consideration of staff rotas, staffing levels would appear to be calculated having considered the assessed needs of residents. Rotas evidenced that staffing levels are normally the registered manager, four care staff, the cook and an auxiliary carer who had responsibility for serving refreshments during the morning shift. In the afternoon and evening shift there are three carers on duty. At 10 00 pm this reduces to two awake care staff. Mrs Wells said that she and Mr Chris Graham, director of the care home calculate staffing levels using the Residential Forum Guidance format. She said that she is aware of the need to make changes to reflect residents’ needs as required. An example of this was the provision of escorts for hospital appointments. Mrs Wells said that currently nine care staff out of the eighteen care staff have completed National Vocational Qualification (NVQ) Level 2 in care. The home Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 22 is therefore meeting the minimum ratio of 50 trained care staff with NVQ level 2 or equivalent. A further six care staff have been signed up to start this training. In addition a senior staff member has enrolled on a NVQ level 3 in care. Staff recruitment files for three care staff were sampled and inspected. One of these files was for a new staff who has been employed since the last inspection. Overall, the staff recruitment practice and record keeping were in good order. The only exception was in the staff recruitment practices and paperwork held for a worker employed under a Supported Employment Programme. These were incomplete and did not evidence compliance with requirement. Skills for Care - Common Induction Training is now in use. This was confirmed in discussion with a new staff member who confirmed that they started on an Induction Training Programme. They confirmed that they felt fully supported by the registered manager, Mrs Wells and “staff were supportive” and involved in their supervision during the induction training. Examples of staff training evidenced and discussed at the site visit were the planned Dementia Awareness distance learning course which is to be completed by the registered manager and four other care staff and recent health and safety and first aid updates via videos. This is in addition to basic training courses completed, which are listed in the Management section of this report. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 23 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 good. This judgement has been made using available evidence including a visit to this service. The home has a competent and experienced manager to run the home. The home has developed a quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the residents. Residents’ financial interests were safeguarded through invoicing residents and their relatives/representatives for additional expenditure. Safe working practices are promoted through ongoing training. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 24 EVIDENCE: Having completed the Registered Manager’s Award Adults Mrs Wells said that she has enrolled on the NVQ level 4 in care. An assessor is due to visit the home to assess her first module and Mrs Wells said that she is hoping to complete this training in twelve months. Management support is provided by the responsible individual, Miss Samantha Racey who has also obtained the RMA (Adults) and the company director, Mr Chris Graham. Since the last site visit, residents have completed a quality assurance survey. An analysis has been completed and published and changes have been made. A good example of this was with regard to menu planning, when oven fish and chips came up as a favourite and as a result they have been introduced each Friday. Other changes to the menu planning are referred to earlier in this report and these have also come about following this survey work. The provision of a large screen plasma TV with surround sound had been purchased following consultation with residents who had spoken of difficulties hearing and seeing the TV screen. Consultation also takes place at Residents Meetings. Recent minutes of the January Resident Meeting highlighted menu changes and discussion, favourite social activities and the new TV. In addition, clarification had been given as to staff roles and staff recruitment practices and as a result some residents had expressed a wish to be closer involved in meeting and interviewing new staff members. Residents had devised questions and management had said that they were looking to incorporating these into the home’s recruitment practices. Mrs Wells said that the practice of the care home is to invoice residents and their families and representatives with regard to additional expenditure. She said that the majority of the relatives involved in the care home undertake some shopping for residents, although the home will assist with this if needed. Safe working practices are promoted through supervision and basic training courses. Mrs Wells said that all staff receive moving and handling and fire safety training annually. She spoke of the home having recently received a very informative fire safety training course, which had been enjoyed by all staff. First Aid training is also offered annually, with all senior staff completing more in depth training every three years. Other courses offered are food hygiene and an infection control correspondence course. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 25 Regular Regulation 26 visit reports are received by Commission for Social Care Inspection (CSCI). In the absence of the responsible individual – Miss Samantha Racey these are being completed by Mr Chris Graham, director of the home. Prior to this inspection copies of the gas maintenance and the electrical installation certification were sent to the Commission and these met requirements. Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 17 (2), Schedule 4 Requirement The registered person must ensure that staff recruitment practices are followed and in place for all staff including employees who are part of a Supported Employment Programme. The registered person must ensure that the registered manager has the required qualification in care a NVQ level 4. Timescale for action 18/05/07 2. OP31 9 (2)(i) 30/04/08 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 Woodlands (Colchester) Ltd DS0000061910.V331288.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 (Colchester) Ltd DS0000061910.V331288.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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