Inspecting for better lives Key inspection report
Care homes for older people
Name: Address: Woodlands HFE Warwick Avenue Clayton le Moors Accrington Lancashire BB5 5RW The quality rating for this care home is:
one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Maureen Brown
Date: 2 4 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area.
Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection.
This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home
Name of care home: Address: Woodlands HFE Warwick Avenue Clayton le Moors Accrington Lancashire BB5 5RW 01254394732 01254396400 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Lancashire County Care Services care home 44 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places - 31) Dementia - Code DE (maximum number of places - 13 The maximum number of service users who can be accommodated is: 44 Date of last inspection Brief description of the care home Woodlands HFE is registered with the Commission for Social Care Inspection to provide personal care and accommodation for up to 44 older people. Within the overall total there are 31 service users aged 65 years or over and 13 service users aged 65 years Care Homes for Older People
Page 4 of 29 Over 65 0 31 13 0 Brief description of the care home or over with dementia. All require personal care. The building is single storey in its own grounds and is located just off the main Whalley Road of Clayton-Le-Moors in Accrington. Whalley Road is situated on a main bus route that offers transport to towns in the Hyndburn area. There is also a well-attended day service sited in the building. The building refurbishment is now complete and provides accommodation with modern furnishings within 3 separate units for the service users. A number of bedrooms are en suite. There are also a number of assisted bathrooms, shower rooms and toilets for the service users throughout the home. Care Homes for Older People Page 5 of 29 Summary
This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. We carried out an unannounced visit to the home on 24 February 2009 and the visit lasted nine and a quarter hours. It was done by one inspector. The report will say we when referring to what was done and found at the visit as it is written on behalf of the Commission for Social Care Inspection. The visit was just one part of the inspection. Before the visit the home manager was asked to complete a questionnaire to provide up to date information about the home. We sent out questionnaires to people living in the home and staff to find out their views about it. Other information received about the home was also reviewed.
Care Homes for Older People Page 6 of 29 During our visit we looked at various records and the home. We looked at the care records of six people who live at Woodlands to see how their needs were being met and looked at four staff records to make sure that appropriate checks had taken place prior to employment. We also had discussions with people who live in the home, the manager and staff team, all of which gave their opinions of the service. The fees for the home are 366.00 pounds to 433.00 pounds per week. Optional extra charges include hairdressing, papers and personal expenses. What the care home does well: What has improved since the last inspection? From the previous inspection six requirements and one recommendation were made. Five of the six requirements have been met and the other one has been partially met and the other part has been made again within this report. The recommendation has been addressed. The statement of purpose and service users guide had been made available so that prospective and current people who use the service have access to this information. The access to suitable activities has improved and an activities coordinator has been employed by the home to promote activities for the people who live at the home. The people who live at the home have three full meals a day offered to them so that their full nutritional needs are met by a varied and well balanced diet. Where people who live in the home are supported by the staff team to cash their pensions, the person who lives in the home and their representatives are aware of the support given and have agreed to this. Care Homes for Older People
Page 8 of 29 Improvements have been made to the access arrangements for the first aid boxes. There is now one on each unit, one in the kitchen and another one in the office. This means that staff have access to a first aid box at all times. To reflect the number and needs of the people who live at Woodlands, most of the staff team have undertaken training in medication awareness, so that the people who live at the home are supported by staff that have adequate training in the administration and safe handling of medication. What they could do better: Three requirements have been made following this visit. The current care plan system must be reviewed and one system adopted and ensure that this is fully completed for all people who live in the home. The controlled drug register must be reviewed on a weekly basis to make sure that it is being completed correctly and that peoples medication is being stored appropriately. Also the staff team must receive formal supervision sessions at least six times a year to ensure that people who live in the home are supported by well supervised staff. Eleven recommendations were made following this visit. We recommend that the review date of the statement of purpose and service users guide is recorded on these documents so that people who look at this information know that it is up to date. A review of the health care notes should be undertaken to ensure that the staff team have up to date information available to them within the care plans. The care plan files should be sub-divided for ease of access to the information. Care plan reviews should be brought up to date and the current information should be kept within the care plan so that the staff team and people who use the service have access to up to date information. People who live at the home or their representatives should sign the care plans to show that they are aware of its contents and that they have been involved in the care planning process. Risk assessments for moving and handling and falls should be completed for each person who lives in the home and these records should be brought up to date. Also other risk assessments should be completed in line with each persons individual needs. Any changes to the planned menu should be recorded so that an accurate record is kept of the menus offered to the people who live at the home. Fridge, freezer and hot food temperatures should be recorded on a daily basis to ensure that the equipment is being maintained appropriately and that hot food is being served at the correct temperature. Staff should receive an annual appraisal so that they have the opportunity to discuss their work and training needs. Residents and staff meetings should be held on a regular basis so that people have the opportunity to have a say on how the home is being run and to ensure it is being run in the best interests of the people who live there. The surveys to people who live at the home and their relatives should be distributed at least each year or in line with the homes policy of every six months, and an analysis should be produced and shared with all relevant parties. Care Homes for Older People
Page 9 of 29 Staff commented on areas where they thought improvements could be made and these included spending more one to one time with the residents and more training. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 29 Choice of home
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive enough information about the home for them to make an informed decision about moving into the home and their needs are assessed before they move in so they know these can be met. Evidence: The statement of purpose and service users guide are kept in a folder with a copy of the complaints procedure. They covered all the areas that people who are thinking of moving into the care home might need to know. This included an introduction to the service, staffing structure, personal care and meeting needs, daily life and social activities and a set of frequently asked questions and answers. They are written in plain English and standard print format. The manager said that copies in other languages and large print could be arranged if requested. A copy of the last key inspection and annual service review were also available with these documents. A copy of these were kept in the hallway and copies were also in each persons bedroom for ease of reference. It was recommended that the review date be included within
Care Homes for Older People Page 12 of 29 Evidence: these documents to ensure that people are looking at up to date information. A previous requirement with regard to up to date information being available for prospective and current people who live in the home had been met. A document is available for staff to gather information prior to someone deciding to live at the home. Information included personal details, next of kin, GP, eating and drinking, personal care, mobility, moving and handling and communication. The person completing the assessment signed the document. The manager uses this information alongside the local authorities core assessment form to ensure that people who move into the home can be well supported by the staff team. The manager confirmed that intermediate care was not provided at Woodlands. Care Homes for Older People Page 13 of 29 Health and personal care
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, personal care and social needs are adequately met by the staff team and privacy and dignity is maintained by the staff towards the people who live at the home. Evidence: We looked at the care plans of six people who live at the Woodlands, to check the care they receive. The information within the care plans was difficult to access, and it was difficult to see which information was relevant and current. It was recommended that the files be reorganised for ease of access to the information. Also two systems seem to be in place, neither of which were fully completed and a requirement was made that one system be adopted and used throughout the care plans for continuity of information. The previous requirement with regard to people who use the service and their representatives being involved in the care planning process had been partially met. Forms were ready in peoples files for people who use the service or their representatives to sign, some of which had been completed. All the night care monthly review sheets were up to date and of the day care monthly
Care Homes for Older People Page 14 of 29 Evidence: review sheets, four peoples records were up to date, two didnt have a record in their care plan file. Care plan reviews ranged from May 2008 to January 2009 and five out of six were out of date and a recommendation was made to bring these up to date. The manager said that some of the information was recorded on the computer system but had not been transferred to the care plan files. The previous requirement with regard to reviewing care plans on a monthly basis had not been met and was made again. The daily notes were seen completed by the staff team. These are kept in one file for ease of access of information for the staff team. Previous notes are kept within each individual persons care plan files. Notes are made during the three shifts across the day and night and these were clear and detailed the well being of the people who lived at Woodlands. The frequency of the recording of these notes was seen to be an area of good practice so that full information about people who live in the home was available for people to see what was happening to each individual person. During this visit the inspector noted that privacy and dignity was maintained by the staff team towards the people who live in the home. The staff worked in a friendly manner with the people who live in the home and showed mutual respect for each other. Staff commented We respect the wishes of the residents and We help elderly people to maintain their dignity and as much independence as possible. A range of risk assessments were included in the care plan files, however, of the six files seen, the risk assessments for moving and handling, one assessment was not dated; one person did not have a risk assessment and one was out of date. Also two people didnt have completed falls risk assessments, and a recommendation was made to bring this documentation up to date and other risk assessments should be completed in line with each persons individual needs. The previous requirement with regard to risk assessments had not been met and was made again. The home uses a monitored dosage blister pack system which is supplied by the local pharmacy. This is kept secure within a locked cupboard. Controlled drugs are used at the home and an controlled drugs register was used to record all transactions. These were checked during this visit and one medication was found to be in error. The controlled drugs register showed one more medication than was actually within the packaging. The error of not recording one administration had been compounded by the receipt of further medication which had not been counted appropriately. A requirement was made regarding this. Care Homes for Older People Page 15 of 29 Evidence: Visits from health care professionals were recorded and it was seen that district nurses, doctors and the chiropodist visited regularly and medication reviews were undertaken annually. However, the current process of keeping this information in a file in the office and on a monthly basis moving it into the care plans was unsatisfactory, in that, the last records on the care plans were dated December 2008. Information regarding visits made in January 2009 had not been transferred and the manager confirmed that this should have been done, and a recommendation was made to review this system as staff did not have easy access to current information. Care Homes for Older People Page 16 of 29 Daily life and social activities
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were able to take part in a range of activities so they can stay active and staff help people to stay in touch with their family and friends. Evidence: An activities coordinator is employed by the home. During discussions with the activities coordinator she said that she had started this role about two months ago and that she was completing a course on activity development training programme, which she was finding very useful as a basis for her role. She also was feeding back to the staff team about what she had learned so that they may benefit from the course as well. Activities undertaken include bingo, dominoes, one to one sessions with individual staff members, crosswords, listening to music, supervised baking and crafts and movement to music. Outside activities have included trips to the local pub for lunch, shopping trips or walks in the park with the staff and a trip to Osthwaite Mill. Planned events for Easter include a concert and spring fayre. An activity log is completed on each unit when these have been completed. Within the main lounge there are a variety of books and magazines some of which were in large print format. Christian and Roman Catholic religious preferences were observed with services for both these denominations being carried out within the home. The activities coordinator has started to develop a getting to know you pack so that staff have an idea of a
Care Homes for Older People Page 17 of 29 Evidence: persons history. This is particularly useful in being able to understand an individuals past and helps the staff understand the individual. The coordinator is hoping to get some photographs as well and develop this into individual diaries of events for each person. The activities coordinator appeared to be very enthusiastic about her role and was looking forward to developing this. The previous requirement about recreational activities has been met. It was suggested that the manager continues to develop the activities plan alongside the activities coordinator. One family member commented There is a lack of activities available during the day and there is limited opportunity to get out into the garden. People who live at the home were offered choices in various ways, such as in the time they get up or go to bed, by choosing what clothes they wear, by deciding whether or not to join in activities and by deciding how they wished to be addressed. This enables them to keep some control over what they do each day and to stay as independent as possible. We looked at samples of menus, of which the daily menu was on display for people to see. A four week menu was used and showed a variety of popular, traditional dishes. There was a choice available at each meal of main course and dessert. The staff checked with people who live in the home about which meals they would prefer beforehand and the cook confirmed that extra portions were made just in case someone changed their mind by the time the meals were served. Drinks were available in between mealtimes and these were seen served during the day. People who live at the home spoken with confirmed that they had enjoyed the meal that they had chosen. During discussions with the cook she stated that some people preferred smaller portions and this was noted on the preference sheet that was completed before each meal. The cook also stated that seasonal or other variations were made to the main menu as required such as having pancakes on Shrove Tuesday, however these changes were not recorded and a recommendation was made regarding this. Records of temperatures of fridges, freezers and hot food had been recorded regularly, however, a new system had been introduced and the records had not been recorded since October 2008, and a recommendation was made for this to be restarted to ensure that equipment is kept at the correct temperature and that hot food is served at an appropriate temperature. The previous requirement regarding offering three meals a day had been met. Care Homes for Older People Page 18 of 29 Complaints and protection
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes procedures for complaints and safeguarding adults are effective so that the concerns of people who live at Woodlands are listened to and they are protected from abuse or harm. Evidence: Staff files were examined during our visit and they showed that training had been completed in safeguarding adults. The manager confirmed this and showed that she was aware of the policy, procedures and guidance on safeguarding. There were also policies available on violence and aggression, whistle blowing, violence at work and Lancashire No Secret policy and procedure. No referrals had been made from the home since the last visit. The complaints procedure was satisfactory and it contained details of how to contact us. We have not received any complaints about his home since our last inspection there. The home had received one complaint which had been resolved to the complainants satisfaction and the appropriate paperwork regarding this was seen during this visit. People who live at Woodlands confirmed they would speak to a member of staff or the manager if they had any problems. A complaint and compliment book was available within the hallway for people to complete and showed thanks from people who live in the home and their relatives for the care and support given by the staff team and the home.
Care Homes for Older People Page 19 of 29 Environment
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained so that people who live at Woodlands live in a clean, safe and comfortable surroundings. Evidence: During our visit we toured the building. We saw all the shared (communal) areas as well as a number of bedrooms. Nineteen of the bedrooms are en-suite. The home has three units two for older people and one for people with dementia. The standard of decor and furnishings are good and the home was clean and odour free. People who live in the home had made their rooms more homely by using ornaments, pictures, photographs and some furniture they had brought with them when they moved in. Some minor damage to walls and door frames was noted on the tour however the manager said that this was being addressed within the maintenance programme during the next year. Care Homes for Older People Page 20 of 29 Staffing
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment procedures are thorough and staff have completed a range of training so people who live in the home are protected from poor practices. Evidence: The staff rota showed the number of staff on duty over the week. The staffing levels appeared to be sufficient to meet peoples needs. People who live at the home confirmed there were enough staff around to help them and during the visit we saw that staff were attentive to peoples needs. However one family member commented There is a lack of staff to meet peoples needs, but the staff do their best. We checked four staff records. They had all the necessary pre-employment checks in place including, identity checks, Criminal Record Bureau checks, references, health checks and application forms. These checks are carried out to make sure that staff are suitable to work with people who live at Woodlands. The training that staff had completed included moving and handling, fire safety, first aid, food hygiene, abuse of vulnerable adults and infection control. It was noted that following a previous recommendation regarding medication training that twenty-one out of thirty-seven staff had undertaken this training and the recommendation had been addressed. Specialist training included dementia awareness, recruitment and selection, personal development and Mental Health awareness.
Care Homes for Older People Page 21 of 29 Evidence: Good progress has been made with National Vocational Qualification (NVQ) level 2 training in care. Twenty-six out of thirty-seven staff have NVQ level 2 or 3 and the residential care officers have or are obtaining NVQ level 4. This means that a high percentage of staff have a nationally recognised qualification in care to help them provide good quality support for the people who live at the home. Staff commented We receive in house training and are regularly updated on changes. We get training on NVQ and moving and handling from the local college and Induction is very good, plenty of information. Care Homes for Older People Page 22 of 29 Management and administration
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The procedures within the home are thorough so the health, welfare and safety of the people who live there are protected. Staff are supervised well on a day to day basis. Documentation regarding meetings with people who use the service and surveys is unclear to show if the home is run in the best interest of the people who live there. Evidence: The manager is registered with the commission and has NVQ level 4 in management and the registered managers award. She has twelve years managerial experience working for the local authority and three of those years has been as the manager of Woodlands. There is an established quality assurance process for the home which includes meetings held with people who live at Woodlands and the staff team who work on each unit, monthly visits to the home by the provider and surveys to people who live at the home and their relatives twice a year. However, the surveys were last given completed in September 2007 and an analysis of this was seen during this visit.
Care Homes for Older People Page 23 of 29 Evidence: Comments included This is an excellent care home, very caring and considerate staff, The manager has been kind and helpful, I feel my relatives care is excellent and all the staff are second to none and I am very happy with the care I receive. A recommendation was made regarding the frequency of the surveys. Meetings within the three units for both people who live at the home and the staff team were not up to date. The manager stated that these should be held every month however, records seen showed that these had last been completed in September, October and November 2008, and a recommendation was made to bring these up to date and that copies of the minutes should be readily available to the people who live at Woodlands and the staff team. The provider visits the home on a monthly basis to check that the home is being run appropriately. Copies of these reports were seen for January and February 2009 and were up to date. Some monies for people who live at the home are held for safe keeping by the manager. This is kept secure in the safe. Two peoples monies were checked and found to be in good order. Appropriate records were also seen at this time. Following a previous requirement where people who live in the home are supported by the staff team to cash their pensions, the person who lives in the home and their representatives are aware of the support given and have agreed to this, and this is now met. Day to day supervision of staff was good, however, formal supervisions were not up to date, of the four staff records looked at, three were out of date, and a requirement was made that supervision sessions must be undertaken with the staff team at least six times a year. It was seen that some annual appraisals had been undertaken in the past however, again these were not up to date and a recommendation was made. Safe working practices were in place in the home. There were up to date safety checks on the homes gas installation and electric wiring system. There were policies available in the home about safe working practices including a range of risk assessments, Accident and incidents, safe moving and handling, RIDDOR, health and safety and food safety. We also saw the fire safety equipment tests log book and up to date checks had been made on th fire safety system and staff received regular fire safety training. Following a previous requirement first aid boxes are available to the staff in all the units, the kitchen and the office and the requirement is now met. Care Homes for Older People Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 29 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 7 15 Two systems of care plans were seen to be in place, neither of which were fully completed. One system must be adopted and used throughout the care plans for continuity of information. 18/04/2009 2 9 13 Controlled drug records must match the medication held within the home. The controlled drugs register showed one more medication than was actually within the packaging. The error of not recording one administration had been compounded by the receipt of further medication which had not been counted appropriately. 27/03/2009 3 36 18 Staff members must have formal supervision sessions at least six times a year. 29/05/2009 Care Homes for Older People Page 26 of 29 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action To ensure that well supervised staff support the people who live at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 1 The review date should be included within the statement of purpose and service users guide to ensure that people are looking at up to date information. Risk assessments for moving and handling and falls should be completed for each person who lives in the home and these records should be brought up to date. Also other risk assessments should be completed in line with each persons individual needs. People who live at the home or their representatives should sign the care plans to show that they are aware of its contents and that they have been involved in the care planning process. The care plans should be reorganised for ease of access to the information so that the staff team can easily access this with regard to the people they support within the home. Care plan reviews should be brought up to date and the current information should be kept within the care plan so that the staff team and people who use the service have access to up to date information. Information regarding health care visits which are kept in the office until the end of the month should be reviewed as staff did not have easy access to current information. Records for fridges, freezers and hot food have not been recorded since October 2008 and should be restarted to ensure that equipment is kept at the correct temperature and that hot food is served at an appropriate temperature. 2 7 3 7 4 7 5 7 6 8 7 15 Care Homes for Older People Page 27 of 29 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 8 15 Seasonal or other variations to the main menu should be recorded so that a clear record is available of the meals served to people who live at Woodlands. Resident and staff meetings should be held every month in line with current practice and copies of the minutes should be readily available to the people who live at Woodlands and the staff team. Surveys should be completed every year or in line with the homes policy which states they will be completed every six months, so that the views of the people who live at the home can be used to influence future planning of the home. Staff members should receive an annual appraisal so that the staff have the opportunity to discuss their work, future training needs and their job role for the future. 9 33 10 33 11 36 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 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. 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!
