Inspection on 01/06/06 for Woodlands Manor

This inspection was carried out on 1st June 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodlands Manor 23/11/09

Woodlands Manor 17/07/07

Woodlands Manor 25/10/05

Woodlands Manor 18/11/04

Woodlands Manor 28/07/04

Woodlands Manor 07/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodlands Manor Ruffet Road Kendleshire South Glos BS36 1AN Lead Inspector Andrew Pollard Unannounced Inspection 1st June 2006 09:45 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 Manor DS0000059729.V297299.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 Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Manor Address Ruffet Road Kendleshire South Glos BS36 1AN 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) 01454 250593 Woodlands Manor Care Home Ltd Mrs Cheryl Lynn Lawrence Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (5) of places Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. May accommodate up to 40 persons aged 65 years and over who are receiving nursing care Of the total of 40, up to 2 persons (who must be aged 65 years and over) who are receiving personal care only may be accommodated. Manager must be a RN on parts 1 or 12 of the NMC register. Of the total of 40, up to 5 persons aged over 50 years may be accommodated that have a physical disability (PD) Staffing Notice dated 19th May 1998 applies, together with amendment dated 16th February 2006 25th October 2005 Date of last inspection Brief Description of the Service: Woodlands Manor is a part converted and part purpose built home registered in November 2004 by Woodlands Manor Care Limited and operated by the directors Mr and Mrs Jenkins. Mrs Jenkins is the Responsible Individual (RI) for the Home. The home is situated in a rural location, but is on a local bus route to Bristol and Yate and is accessible to local shops and amenities by car. Communal areas are provided by way of a dining room, lounges and large conservatory area. There is level access throughout the home and all areas of the home are accessible via a lift. There are a suitable number of bathrooms and toilets with adaptations to meet the care needs of residents in the home. Appropriate equipment can be provided for individual use based on assessed or identified needs. All rooms have a call alarm system. The home is set in its own grounds, which are beautifully maintained and accessible to residents. Car parking is available for several cars. Visitors are welcome to the home at any time. In house activities and entertainments are provided. The fees range from £610 to £700 per week for single rooms, additional charges are made for Chiropody, hairdressing, newspapers, dry cleaning and private telephones. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Ten residents were spoken with and surveys were received from fifteen residents. Several staff and four relatives were consulted. Four comment cards were received outlining people’s views of the Home and the service provided. The inspector spoke to the manager, Registered Nurse (RN’s), care assistants and ancillary staff about their roles and responsibilities. A range of records relating to the day-to-day running and management of the Home were inspected. A selection of resident’s care records and care plans were reviewed. Tour of premises. Further unannounced inspections will be carried out to monitor the progress. What the service does well: Staff morale had been low in the past, however the majority of residents and visitors consider the atmosphere is changing and the staff appear happier and more positive. The management team and the Responsible Individual remain committed to improvements in the working environment and quality of life for the residents and are seeking to work cooperatively with the whole staff team to achieve this. People are treated as individuals and their physical and mental health needs are met. Staff were observed assisting and interacting with residents in a caring and friendly manner. Comment cards and surveys gave a variety of views but in general they were positive, however there were three negative responses that are regarded as complaints, which are being dealt with by the manager. The environment internally and externally is of a very high standard, and appreciated by residents. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Put on public display for the benefit of residents and visitors a copy of the service user guide including the most recent inspection report. Create a Criminal Records Bureau (CRB) disclosure log and where necessary complete written risk assessments to evidence how residents are protected from unsuitable staff. Ensure staff respond to residents toilet needs and other requests urgently to maintain their dignity. Develop social activities assessments, plans and records. Maintain a system for reviewing and improving the quality of care in all aspects of a resident’s life. Consider setting up a relative forum. The manager should sign and date load handling assessments to show that the safety of staff and residents is being promoted. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 7 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. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 The overall quality of this outcome area is adequate. Prospective clients and their families are given relevant information in written or verbal form about the home. Contracts and terms and conditions of services are provided to all clients. The assessment procedure is clearly written and a thorough assessment of prospective residents needs is carried out. EVIDENCE: The statement of purpose (SOP) and service user guide SUG documents meet the regulatory requirements, are comprehensive and written in plain English. A page giving details of the breakdown of the fees have been added. No intermediate care is offered. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 10 The manager or senior Registered Nurses (RN’s) visits and assesses prospective residents. A new admission procedure has been developed that takes into account the dependency rating of the existing residents group and staffing numbers and skill mix. Team leader RN’s sit in on all PCT nursing contribution assessments. On occasions urgent admissions are accepted if they have written health and or social care assessment documentation. All residents have Waterlow, handling and continence assessments. Each person has a handling assessment some of which have been carried out by delegation from the manager in future as the competent person the manager should countersign and date these documents. Residents care records were reviewed to ascertain how residents care needs are assessed. The assessment records showed assessment of the person’s physical, mental and social needs had been carried out. At present there is no thumbnail biography or social care assessment but this should be rectified following the recent appointment of an activities organiser. The Standex dependency rating has been introduced and is reviewed monthly. The majority of residents are in the medium high dependency banding. The overall dependency is in accord with the current staffing arrangements although there are pinch points around toileting at meal times. All residents have recently received updated written terms and conditions weather they are privately funding or funded by Social Services. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The overall quality of this outcome area is good. The staff provide appropriate personal and nursing care to maintains residents’ health and well-being. Proper arrangements are in place for residents to access primary healthcare services. The staff properly store, administer and record medication on behalf of residents. Care plans detail residents care needs and are clearly written. EVIDENCE: Named RN’s take responsibility for a group of residents and with the residents and their key worker evaluate and update care plans. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 12 The Standex system of documentation is in use and the activities of daily living is the model of care on which care plans are based. Newly admitted residents are given a core care plan within the first week, which is evaluated with the resident or their representative and updated as the person settles in. Six residents care plans were inspected which addressed the physical and psychological health care needs of the person and did clearly show how to assist the residents to meet their assessed needs. The resident survey asked “Do you receive the care and support you need?” Of 15 responses, 5 said always, 7 usually, and 3 sometimes. Comments included “waiting time is the most annoying” and “I am very satisfied with the care I get”. A small number of residents stated verbally or through surveys that while staff were kind they have to wait for varying periods of time if they require assistance to go to the toilet, however the number of such comments have reduced. The home monitors response times to call bell alerts and this showed that in general the response time was within a few minutes. At the last inspection the value of key workers preparing short biographies of residents as a way of developing relationships and a more person centred approach was discussed. To date only one biography has been completed. In general the case files give detailed information stating how best to meet the residents needs and demonstrating that health care needs were being monitored and kept under review. Annual reviews are planned to take place when the PCT reassessment is carried out as the named nurse assists in this process. All bar one of the residents surveyed were content with the support they received for their health care needs. The GP records are kept as part of the case file. There are records of visits by opticians, dentists and chiropodists. The home has good support from the hospice and they facilitated recent training in pain control in the home. The manager and five staff are to take part in the Hospice “End of Life” initiative over six months with sessions in the Hospice and at Woodlands. Medication procedures and practices in the Home were reviewed, and the Home operates a safe system of storage, administration and recording of medication. Disposal arrangements are in line with current legislation. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 13 The home has drug fridge drug fridge and suction equipment. At present no residents wish to or are able to manage their own medication. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The overall quality of this outcome area is adequate. The home has provided a limited range of social activities for residents. Residents are able to maintain close contact with families and friends. The Home provides a balanced diet for residents. EVIDENCE: The activity organiser has retired and a new person appointed for ten hours a week, however at the time of the site visit they had just taken post so the outcomes were not yet evident. A volunteer provides music and movement each week. A newsletter is sent to residents and relatives every three months. Many of the residents spoken to said how much they would enjoy arts and crafts, games and quizzes and entertainments but little happened. When surveyed and asked, “Are there activities arranged that you can take part in” 4 Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 15 said always, 2 said usually, 4 said sometimes, and 5 said never. Two letters were received from visitors who criticized the lack of activities. The expectation is that the new activity organiser and the manager will conduct a survey of resident’s wishes and develop social assessments and records for each resident. A programme of activities and entertainments will be developed including the care staff where practical. A number of fundraising events are taking place around the upcoming World Cup. The home has an open visiting policy and several visitors were seen coming in and out of the home at different times of day. There has been quite a lot of contact between relatives and the commission indicating a considerable interest in the services offered by the home. The suggestion was made that the manager set up a relative forum on a quarterly basis. A quality survey related to food was carried out with 12 residents, 7 staff and 3 visitors taking part. All residents were also asked to list favourite and least favourite foods. As a result the chef is creating new menus. A number of residents spoken to say that the meals have improved and of those surveyed 66 said they always or usually liked the meals and 20 sometimes. The menu offers choices of meal, which were nutritionally well balanced. Residents are asked their wishes in the afternoon for the following day. Woodlands Manor DS0000059729.V297299.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The overall quality of this outcome area is adequate. The Home addresses complaints made about the service. The Home supports residents to uphold their legal rights. Proper arrangements are in place to protect residents from abuse. EVIDENCE: The Home’s complaints procedure is included in the service user guide, and a copy is given to residents on admission. There is a copy of the complaints procedure on display in the main foyer. Over the last few weeks the commission has received a number of telephone calls and copies of written complaints that have been sent to the home. The complaints were from relatives and some were anonymous. Two of the complaints were discussed at the site visit and the manager is responding to them, they relate to issues of dignity, toileting, record keeping and provision of timely care. No complaints were raised on the day of inspection from residents, visitors or staff. However it was mentioned several times in conversations that certain staff had a tendency to talk over them to their colleagues or that they could be ill-tempered on some occasions. The view of two nurses and three visitors was Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 17 that a more positive and constructive atmosphere is developing and staff morale rising which should reduce the number of complaints. No allegations of abuse have been received. The home has the Local Authority “Protection of Vulnerable Adults (POVA) inter-agency reporting procedure”. The manager has attended Local Authority POVA training and the staff are booked onto the course two at a time as places arise. The home also has a video training pack and workbook, which is to be used at induction and for updates. The home had formulated written procedures for adult protection; whistle blowing and management of resident’s money/valuables. Woodlands Manor DS0000059729.V297299.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,26 The overall quality of this outcome area is excellent. The standard of furnishing and décor is high to the benefit of residents. The Home is safe, well maintained, and suitable for the needs of residents both internally and externally. The standard of cleanliness is high. EVIDENCE: The Home is built in landscaped gardens, has a large fish pool and peacocks roam the grounds. The gardens are fully accessible for wheelchair users as well as to the more able-bodied and are very popular and well used by residents and their visitors in warmer weather. Rooms a t the front of the building have access to a veranda. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 19 The home creates a feeling of homeliness, with sufficient space and facilities for older people. There are suitable adaptations in place throughout the Home, to assist residents who may have limited mobility. The home is over two floors. There is level access to all areas via two passenger lifts. The home was well maintained. It was warm, well decorated and furnished and cleaned to a high standard. The home operates a no-smoking policy. Residents can chose to socialise in one of the communal lounges or conservatory or have quiet time in their own rooms. All bedrooms were well presented, offering appropriate furnishings and fittings relevant to need. When surveyed 75 of residents said the home was always clean and fresh and 25 said it was usually so. All verbal comments were in praise of the quality of the environment and its upkeep. Individual residents, with their families and/or friends, have personalised rooms with photographs, plants, TV, smaller items of furniture, etc. A number of the bedrooms have en-suite facilities and there is good provision of communal bathrooms and toilets. Resident areas are fitted with appropriate aids such as grab rails, fixed and mobile hoists. All rooms have a nurse call system with audible alarm facility. Sluice areas included sinks and a washer disinfector on each floor. The laundry has sufficient washing machines and tumble dryers. Two residents praised the quality of the laundry service; there was one complaint about sheets not being changed. There are appropriate infection control, policy and procedures in place. There are good arrangements in place for the service and maintenance of plant and equipment. Maintenance staff are employed providing full time cover for the home and gardens. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The overall quality of this outcome area is adequate. The staffing levels meet the minimum standards for the number of residents. The recruitment process is well managed. There is a commitment to improving care staff training. EVIDENCE: In the recent past there was evidence from care staff, residents and relatives that indicate that staffing levels were too low to meet resident’s needs. At this inspection there were very few comments of this nature either verbally or in surveys and comment cards. Comments cards and surveys from residents stated that staff themselves were generally very kind and hardworking and attended to them as soon as they could but often seemed very busy. When surveyed and asked “Are the staff available when you need them”, 40 said always, 47 said usually and 13 said sometimes. The nature of admissions and high dependency of some residents is a key factor in this situation and the manager and RNs have adopted a dependency assessment that relates needs to staffing and will assist in decisions about the suitability of admissions when related to staffing numbers and skills. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 21 A new staffing notice has been agreed and is now a condition of registration. The home has been staffed in accord with the requirements of the notice with occupancy of 33. The staffing levels are; AM, 6 care staff and 1 RN, PM, 5 care staff and 1 RN, Night, 3 care staff and 1 RN. The manager’s hours are in addition to the above. There are currently two care assistant vacancies one on days and one on nights. There is a full time and part time chef. A kitchen assistant is on duty every Day. A bank cook is available to cover leave and sickness. A laundry person works every day. A new weekend housekeeper has been appointed bringing the number to three seven days per week. A maintenance man works full time. An activity organiser has been appointed for ten hours a week and a volunteer attends once a week. One of the night Sisters provides admin support once a week. The recruitment records were in good order and all the required references and checks carried out. All staff have CRB disclosures but there is no log record. The manager is to devise a log with the name, date, CRB ref number and indication of outcome or risk assessment carried out. A CSCI inspector will check the disclosures and sign the log so the documents can be confidentially destroyed. Two disclosures required risk assessment but such had not been formally recorded, this has now been carried out and submitted to the Commission. All staff complete a revised induction programme of which written records are made. It was accepted that on occasions the load handling training was not provided as soon as practical, the manager has undertaken to resolve this. Basic training for all staff includes updates on POVA, infection control, 1st aid, and food hygiene, health and safety and fire safety. A training matrix is in use to monitor staff updates. At present nine care staff are on NVQ level 2 programmes and one doing level 3 through the Norton Radstock College. The RN training arrangements and records will be looked at the next site visit. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,38. The overall quality of this outcome area is adequate. The manager is trying to create an open and constructive ethos in the home to the benefit of residents. The Responsible individual does not write Regulation 26 reports. Surveys of resident’s views and opinions are being sought. Staff supervision is taking place. The Home protects the health and safety of residents and staff. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 23 EVIDENCE: The inspector-spent time talking with staff, to ascertain their views. In discussion with the inspector Mrs Lawrence stated her commitment to build staff confidence and improve morale. The importance of finding a balance between the demands of office work and the emphasis on closer interactions with the care staff was discussed. The manager had achieved many of the tasks identified for action in the last report and will need to develop ongoing action place to address outstanding and new matters identified in this report. Mrs Jenkins has conducted one recent supervision session with the manager and held weekly meetings, some by phone. The regulation 26 reports had not been submitted monthly as required, however brief reports for April, May and June were received on the 13th of June. The one to one supervision sessions have been fully reinstated every two months by cascade through the team nurse structure, the RN’s conducting the one to one supervision sessions with the care staff that are key workers in the teams they oversee. There have been two recent care staff meetings in March and April for which minutes were seen, thereafter meetings are to be bi-monthly as are RN clinical meetings. The manager attends the quarterly S.Glos home manager meeting and the care home learning network at St Monica’s. The manager and deputy are undertaking the NVQ care manager award through Norton Radstock College. The Home is able to look after resident’s personal spending money, and provides a secure safe for this purpose if they request it. Each person has a ledger sheet recording receipts, debits and balances. Two signatures are required to endorse any debits. Four resident ledgers and cash balances were checked and found to be in order. The valuables held for safekeeping have been recorded in a book but were stored in the drug cupboard. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 24 The Home has a range of Health and Safety (H&S) policies and procedures in place to ensure the safety of residents and staff. The manager is a load-handling instructor and has completed H&S management training. The accident records were fully completed and followed up. There are up to date service and inspection records for; hoists, lifts, gas supply, electrics and fire alarm and extinguishers. The kitchen was very tidy and well organised. An Environmental Health Officer last visited in January and found all to be in good order. The kitchen undergoes periodic deep cleaning. The manager has written a new policy on the review of quality issues. There has been one formal surveys of resident, relative or staff views with regard to the choice and quality of food and the manager is planning to conduct a number of themed surveys in the future. (Refer to standard 12 & 15) Eleven residents were spoken to on the day and in general their comments were positive and said they felt that all the staff worked very hard were helpful and caring but on occasions seemed in a rush or they had to wait longer than they wanted to, to be attended to. Some residents that had more recently moved in were happy with their choice given that they would rather not being residential care at all. Some positive comments included “I am looked after very well and couldn’t be happier”, “ My first impressions are very good”, and “I think standards have risen, the staff are helpful, the food is good and I like my room”. One visitor said, “The staff morale and attitude have noticeably improved and things are generally better”. Another visitor said “My previous complaints have been resolved and in general I am pleased with the care although sometimes there is still a lack of attention to detail. Overall the staff are doing their best”. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 25 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 2 x 2 X X X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 x X X 3 X 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 3 x 2 x 2 2 x 3 Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 Schedule 2(7) Requirement Create a log of disclosures to be signed by a CSCI inspector. If a disclosure reveals convictions make a written risk assessment if the intention is to employ. Consult with residents about their social interest and developing a programme of activities. Submit a report monthly in the format set down by the regulation. This is a re-dated requirement from the last report. Timescale for action 10/07/06 2. OP12 16 (2) (m) (n) 30/07/06 3. OP33 26 01/07/06 4. OP1 5.1 Put on public display for the 30/06/06 benefit of residents and visitors a copy of the service user guide including the most recent inspection report. This is a re-dated requirement from the last report. Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 27 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. 3. 4. Refer to Standard OP3 OP35 OP33 OP33 Good Practice Recommendations The manager signs and dates all load handling assessments. Resident’s valuables should be held in the safe not the drug cupboard. That the manager set up a relative forum on a quarterly basis as part of the quality monitoring system. Maintain a system for reviewing and improving the quality of care in all aspects of resident’ s life. Ensure staff treat residents with dignity by responding to their requests as quickly as possible. That the Responsible Individual provides regular and faceto-face supervision and conducts management review in the home. 5 6. OP10 OP36 Woodlands Manor DS0000059729.V297299.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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 Manor DS0000059729.V297299.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. 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. 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