Inspection on 04/06/07 for Woodlands Manor

This inspection was carried out on 4th June 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 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 05/10/06

Woodlands Manor 23/01/06

Woodlands Manor 10/08/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Woodlands Manor 21-23 Chambres Road Southport Merseyside PR8 6JG Lead Inspector Daniel Hamilton Key Unannounced Inspection 4th June 2007 9:15 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 DS0000064444.V341688.R02.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 DS0000064444.V341688.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Manor Address 21-23 Chambres Road Southport Merseyside PR8 6JG 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) 01704 544848 Woodlands Manor Ltd Mrs Lyndsey Emma Floyd Care Home 27 Category(ies) of Dementia (27), Old age, not falling within any registration, with number other category (19) of places Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection No service users can occupy rooms on the second floor until such time as the Commission for Social Care Inspection is satisfied that they are suitable for occupation. Until such time that a lift serves the second floor, the rooms once converted may only be used by ambulant service users. No further service users within the OP category may be admitted into the home. 5th October 2006 Date of last inspection Brief Description of the Service: Woodlands Manor is a privately owned care home which is registered to provide personal care and support for up to 19 older people or a maximum of 27 older people with dementia. The home is situated in a quiet residential area, not too far from the centre of Southport and all its amenities. Public transport is available close by. The premises consist of two large houses joined together by a central link and has four levels (including a basement). The basement and ground floor are serviced by a passenger lift and the main entrance is accessible via a ramp. The communal areas in the home consist of a dining room and two lounges, one of which is attached to a conservatory. The home is equipped with a hoist and assisted bath and toilet facilities are located throughout. A call bell system with an alarm facility is fitted in each bedroom and also the communal areas. There is a large garden to the rear, which is well maintained. Off-road parking is available at the front of the premises. Care Home Fees range from £394.50 to £425.00 Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 9.5 hours. 24 residents were living in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Registered Manager, Deputy Manager, care staff, relatives and residents were spoken to during the visit. Care Home Survey forms were also distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional feedback about the home. None of the surveys had been received by the Commission before the inspection took place. All the core standards were assessed and action taken in response to previous requirements and recommendations from the last inspection in October 2006 was reviewed. What the service does well: Residents and relatives spoken with reported that the were generally satisfied with the standard of care provided. Comments included; “Everything is great. It’s been wonderful so far and I am well looked after”; “The staff look after me very well” and “I am very contented here.” The home had produced written information on the home in the form of a ‘Service User Handbook’. The document was available for reference and relatives and their relatives confirmed they had received written information on the service prior to moving in. The home had assessed the needs of prospective residents prior to admission and copies of social work assessments had been obtained for people referred through Care Management arrangements. Residents reported that they had access to medical services subject to individual need and records of health care visits / appointments had been maintained by the home. One resident reported; “If your not well the staff will get the doctor quickly.” The home had established systems for the recording, handling, storage and administration of medication and medication checked was generally administered to a satisfactory standard. Meals were well managed and residents were observed to enjoy their meal times in a relaxed and pleasant environment. Menus offered a choice of Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 6 nutritious and wholesome meals and feedback from residents was positive. Comments included; “I’ve not had a bad meal yet. The catering is good”; “The food is out of this world” and “The food is always very good here.” What has improved since the last inspection? What they could do better: The service had developed a detailed Care Planning System however some Care Plans viewed, were vague and lacked important information. Care plans must be updated to include information on all the needs of the people living in the home and the support required to achieve objectives, to improve record keeping and to safeguard the welfare of residents. At the time of the visit the home did not have an up-to-date electrical wiring certificate. A certificate must be obtained to confirm the wiring installation is safe for the people living in the home. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 7 Although the home continues to receive ongoing maintenance and investment, the home should prioritise the repair of the damaged carpet on the first floor landing and the dampness in the hairdressing salon, to minimise the risk of a trip hazard and to protect the health of residents. The home had produced a programme of activities for residents to participate in. This should be kept under review and developed in accordance with current literature and best practice, to ensure the home introduces additional activities for people living with dementia. Training records were not up-to-date at the time of the visit and some gaps were noted for Safe Working Practice topics including Infection Control, Fire and Food Hygiene Training. Training records should be kept up-to-date to enable an accurate assessment of the training needs of staff. Furthermore, the manager should complete a National Qualification in Care at level 4 or equivalent, to ensure she has the necessary qualifications for her role. The home benefited from an external and internal Quality Assurance Assessment process. It was noted that the home’s quality assurance summary record sheet did not indicate the period of the assessment. This information should be included for interested parties to view. A Complaints procedure had been developed by the home to enable residents and / or their representatives to express their concerns formally. Records showed that one complaint had been received since the last visit however the home’s records did not indicate that the outcome of the complaint had been shared with the complainant. The manager was advised to record this information and to share the outcome of complaints with the relevant people, to improve record keeping and communication. 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 Manor DS0000064444.V341688.R02.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 DS0000064444.V341688.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes preadmission assessments and provides residents and / or their relatives with information on the service. This enables people to make an informed choice as to whether the home is able to meet their needs. EVIDENCE: Previous inspection records confirm that the home had developed a Statement of Purpose / Service User Handbook to provide prospective residents and / or their representatives with key information on the service provided at Woodlands Manor. On the day of the inspection, the documents were available for reference and relatives and residents spoken with confirmed that they had received written information on the service prior to moving in. Evidence was also available in residents’ files, to confirm a copy of the Service User Handbook had been given to relatives or their representatives prior to people moving in. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 10 Three files were examined during the visit for residents who had moved into the home since the last inspection. Only one of the three files viewed contained a signed ‘Service User’s Contract of Admission.’ The manager was able to provide evidence that the Contracts had been issued prior to admission, however the Provider’s copy had not been returned. Files also contained a range of pre-admission, health and functional assessment information, which had been completed by senior staff in the home. The assessments had been designed to enable staff to undertake an holistic assessment of need and some information on each resident’s mental health had been included. Copies of social work assessments and care plans had been obtained for residents referred via care management arrangements. Records showed that the manager had written to residents and / or their representatives following an assessment, to confirm the home was able to meet the needs of prospective residents, the proposed admission date and room number. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home manages the personal care needs of residents satisfactorily and staff are able to demonstrate an awareness of residents’ needs. EVIDENCE: The files of three residents who had moved into the home since the last visit were inspected during the visit. Each file was found to contain a care plan, together with a range of additional records including risk assessments, daily report sheets and health care records. Care plans had been structured to outline the needs of each resident, aims of the care plan and support required by staff to meet objectives. Some care plans viewed were vague and lacked information on the intervention required from staff to meet individual needs. For example, only one of the three care plans viewed provided information on the mental health needs of a resident, despite all three residents having a diagnosis of dementia. Furthermore, none of the care plans viewed had been signed by residents or their representatives to confirm they were in agreement with their individual plan of care, however it was noted that some relatives had participated in review meetings organised by the home. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 12 Despite the absence of some key information within care plans, staff demonstrated an awareness of the daily living needs of the people living in the home and the support required to help them. Visits to and from Health Care Practitioners had been recorded and these showed that residents had accessed a range of medical services including doctors, district nurses and chiropodists. Pre-inspection records detailed that in-house or community visits were also available for other support services including dentist and optician appointments. One resident spoken with reported; “If your not well the staff will get the doctor quickly.” The home had a copy of the Organisation’s ‘Medications Policy and Procedure’ and a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain had been obtained for reference. The deputy manager reported that none of the residents self-administered their medication at the time of the visit. Records of staff trained and authorised to administer medication together with a system to check the identity of residents prior to administering medication were in place as noted at the last visit. The manager continued to undertake medication audits and a problem / report file was in place to monitor and identify any issues with medication. Medication checked was found to be stored correctly. Since the last visit, the home had purchased a small cabinet to store controlled drugs and a register to record controlled medication. The deputy manager was advised to store the register in a safe place, as it would not fit into the cabinet. Medication administration records checked were generally maintained to a satisfactory standard. There was one instance where the details of medication received into the home had not been recorded to provide an audit trail and this issue was discussed with the deputy manager. Staff spoken with during the visit demonstrated a good understanding of the principles of good care practice and the need to ensure residents’ privacy and dignity was respected at all times. Residents were observed to be clean and appropriately dressed and staff were observed to be sensitive and attentive to the needs of residents throughout the day. Residents spoken with confirmed they were satisfied with the standard of care provided. Comments included; “Everything is great. It’s been wonderful so far and I am well looked after”; “The staff look after me very well” and “I am very contented here.” Woodlands Manor DS0000064444.V341688.R02.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. Overall, daily life, social activities and meals are flexible and varied to meet the expectations and preferences of the people living in the home. EVIDENCE: The home had a ‘Social Activities Timetable’ that was displayed in the reception area of the home for residents to view. The programme was based on a weekly cycle and listed two or three activities for residents to participate in each day. On the day of the visit a ‘Chair Exercises’ session was being facilitated for a group of residents. Other activities on the programme included; hairdressing, nail care, ball games, bingo, board games, quiz, baking, musical movements, collage making and church outings / visits. Records showed that additional activities including musical entertainers and clothes parties were also arranged from time-to-time. Some residents and relatives felt the programme of activities could be further developed to provide more stimulation for the people living in the home. For example, opportunities for residents to discuss newspaper articles or to reminisce about their life history or events. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 14 The home had developed policies / procedures that acknowledged the rights of residents to make choices and to maintain contact with family and friends. Residents spoken with confirmed that they were able to receive visits from family and friends whenever they wished and visitors spoken with confirmed they were always made to feel welcome. One visitor said; “There are no restrictions on visiting times” Staff spoken with demonstrated a commitment to supporting residents to remain in control of their lives as much as possible. Staff also acknowledged the difficulties in balancing the rights of residents against the duty of care / responsibilities they have in supporting people who lack capacity due to dementia. Residents spoken with confirmed the routines in the home were flexible and one person reported; “You can go to bed whenever you like.” The home had a four-week menu in operation, which offered residents a wholesome and nutritious diet. A copy of the menu was displayed on the home’s dining room notice board and laminated copies were available on dining tables for residents to view. Discussion with the home’s chef and residents confirmed the people using the service had a choice of three main meals each day and that the dietary needs and preferences of current and prospective residents would be met by the home. Additional drinks were served throughout the day Meals were served in the home’s dining room, which was pleasantly decorated and furnished. Tables were set with tablecloths, napkins, condiments and fresh flowers. A meal time was discreetly observed during the visit. Residents were seen to enjoy their meal and staff were available to serve meals and offer support as and when required. Feedback received from residents during the visit confirmed the people in the home were satisfied with the standard of catering. Comments included; “I’ve not had a bad meal yet. The catering is good”; “The food is out of this world” and “The food is always very good here.” Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents or their representatives are able to express their concerns via a complaints procedure so that their rights are upheld and their concerns acted upon. Systems are in place to protect residents from abuse however some staff still require training in abuse awareness, to ensure they understand how to recognise and respond to abuse. EVIDENCE: The home had a developed a ‘Complaints, Suggestions and Compliments Policy’ in a standard format. A copy of the complaints procedure and compliments book was displayed on the home’s notice board and information on ‘Making a Complaint and Giving Compliments’ had also been included in the home’s ‘Service User Handbook’. The home’s record of complaints was viewed during the visit. This showed that one complaint / concern had been received by the home since the last inspection. The complaint was from the relative of a resident in the home and concerned the passenger lift failing to level with the adjacent floor. Records showed that the home had taken appropriate action to address the fault. Advice was given to the manager on the importance of sharing the outcome of complaints / concerns with complainants, as this information had not been recorded. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 16 No complaints had been received by the Commission for Social Care Inspection since the last inspection. Residents and /or relatives spoken with confirmed that they were aware of whom to speak to if they were not happy and that they felt listened to by the manager and staff. One resident reported; “Lyndsey [Manager] is very good and will sort any problems out for us.” The home had policies and procedures in place to Protect Vulnerable Adults from abuse. The policies included an ‘Avoidance of Abuse’ and a ‘Whistleblowing’ procedure. A copy of the local authority adult protection procedures for the City of Liverpool and Borough of Sefton was also available for reference. Training records showed that eleven staff had completed training in the protection of vulnerable adults to date. It was noted that N/A [Non applicable] had been recorded on the training matrix for two staff. The manager was advised to ensure that all staff, regardless of their role, complete training in this important subject as a matter of priority, to ensure all staff understand adult protection issues and their duty of care to protect the welfare of the people using the service. Staff spoken with during the visit confirmed they had completed training in abuse awareness and demonstrated a satisfactory understanding of how to recognise and respond to suspicion or evidence of abuse. An adult protection incident was being investigated at the time of the inspection. This concerned an injury sustained by a resident who had been using the service for respite care. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the environment continues to improve however some areas of the home require attention to ensure residents benefit from a safe, comfortable and homely environment in which to live. EVIDENCE: Woodlands Manor had one part-time and one full time handypersons who were responsible for general maintenance and repair. Job sheets were in place to record work in need of attention and an ongoing maintenance plan had been developed for 2007. Monthly Health and Safety audits were also undertaken. A tour of the premises was undertaken during the inspection. As previously noted, the home is not purpose built for people with dementia - as the bedrooms are situated over three floors (ground, first and second floors) and are not therefore immediately accessible. Please refer to the ‘Brief Description of the Service’ section for more information on the premises’. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 18 Pre-inspection records showed that the home had continued to receive ongoing maintenance and refurbishment. Since the last inspection, 5 new bedrooms with en-suites had been developed on the top (third) floor. Records also showed that an additional five bedrooms had been redecorated. Residents spoken with confirmed that they were generally satisfied with the standard of accommodation provided and rooms viewed had been personalised with photographs, ornaments and various memorabilia. The manager reported that thermostatic valves had been fitted throughout the home and that all radiators had been guarded. Furthermore, security lights had been fitted to the front and rear of the home and a gate had been fitted to the side of the premises. A new washing machine with sluice facility had also been purchased. Overall, areas within the home appeared to be maintained to a satisfactory standard and the external grounds were tidy and attractive. At the time of the visit, the hairdressing salon in the basement was in need of attention as the paintwork had become loose and was flaking due to dampness in the wall. Likewise, the carpet on the first floor landing was in need of replacement as it was damaged and presented a trip hazard. These issues were discussed with senior staff during the visit. The home employed two part-time domestic staff housekeepers. Infection control policies and procedures and Control of Substances Hazardous to Health data sheets were available for staff to reference. No details of infection control training had been included on the home’s training matrix and some staff spoken with reported that they had not completed this training. Overall, areas viewed were clean and fresh and residents and relatives spoken with confirmed the home was kept clean on a daily basis. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are appropriately recruited to protect the welfare of residents. The home has an ongoing training programme that includes dementia care, however some training records are not up-to-date to confirm staff are trained and competent to do their jobs. EVIDENCE: On the day of the visit the home was accommodating 24 residents. Rotas showed that the home was generally staffed with one senior and two carers from 8.00 am to 8.00 pm. During the night, two waking night staff were on duty. The manager worked Monday to Friday each week or as required by the service and ancillary staff were employed for working in the kitchen and for cleaning duties. Day and night care staff were also responsible for laundry duties. Residents spoken with confirmed that staff were available when needed and that they received the care and support they required. One relative reported; “The staff are fantastic” however another relative expressed concern regarding staffing levels. A discussion took place with the manager regarding the number and dependency levels of the people living in the home, staffing levels and duties and the design / layout of the building. The manager reported that home was able to meet the needs of residents with the current staffing levels and that Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 20 she monitored the dependency levels of residents on an ongoing basis. The inspector was advised that staffing would be increased if required. Records showed that the home employed 13 care staff (when fully staffed). Examination of training certificates showed that 7 staff (53.84 ) had a attained a National Vocational Qualification in Care at level 2 or above. The deputy manager reported that another member of staff had completed the training and was awaiting certification and that a further two staff had enrolled to undertake the training course. Previous inspection records confirm the home had appropriate procedures in place for the recruitment of staff. Pre-inspection records and discussion with the senior staff confirmed that five new staff had commenced employment at the home in various capacities since the last inspection. All five files were viewed. Personnel files contained all the necessary records required under the Care Home Regulations 2001, to confirm new staff were fit to be employed with vulnerable adults. Records on file included; application forms, two written references, health declarations, proof of identity, terms and conditions, job descriptions and Criminal Record Bureau checks. Confirmation that Protection of Vulnerable Adult checks had been undertaken by the Organisation’s head office were also available on files viewed. Records were available to confirm that new care staff employed since the last visit had completed induction training in accordance with the ‘Skills for Care’ Common Induction Standards. No evidence of induction could be found for a domestic who had started work since the last visit. This was brought to the attention of the manager during the visit. The home had developed a training matrix. The matrix was not up-to-date at the time of the inspection as the record detailed that some sections of the document had last been updated during March 2006. Therefore, it was not possible to make an accurate assessment of the outstanding training needs of the full staff team, as the details of training completed since the last visit and new staff had not been included on the matrix. Training records showed that a range of Safe Working Practice and other care related training was available for staff to access, which was relevant to their roles and responsibilities. This included training in dementia. Staff spoken with felt the training provided was good and relatives stated that they were of the opinion that staff understood the needs of residents. No details of infection control training had been included on the training matrix and staff spoken with reported that they had not completed the training to date. Gaps were also noted for some Safe Working Practice topics including Fire and Food Hygiene training as previously noted. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 21 The manager was able to provide written evidence that she was in the process of nominating staff for a range of training during June 2007 in consultation with the Organisation’s ‘Training Coordinator.’ This included; Moving and Handling; Food Hygiene; Infection Control; Equality and Diversity; Health and Safety and Infection Control Training. Pre-inspection records detailed that Protection of Vulnerable Adults, First Aid, Fire Safety, Manual Handling, Dementia, Medication and National Vocational Qualification training had been provided since the last visit. Woodlands Manor DS0000064444.V341688.R02.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. 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. Systems have been established to ensure the home is managed and run in the best interests of the people who use the service. EVIDENCE: The manager, Mrs Lyndsey Floyd, was registered with the Commission for Social Care Inspection and had managed the home since approximately June 2005. Prior to her appointment, Mrs Floyd had gained experience as a deputy manager in another home within the Cedars Care Group. The manager reported that she had completed the National Vocational Qualification (NVQ) level 4 Registered Managers Award since the last visit and was awaiting her certificate. Records showed that the manager continued to update her knowledge and skills and had recently completed a Management Training Workshop, Protection of Vulnerable Adults, Medication and refresher training in some safe working practice topics. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 23 At the time of the visit the manager had not completed a National Vocational Qualification at level 4 in Care or equivalent. Staff and residents spoken with during the visit confirmed the manager was approachable and supportive in her role. The home continued to receive an external audit on an annual basis. This assessment was commissioned by the Owner in order to monitor and improve quality. Records were available to confirm the Owner had also undertaken monthly visits and produced reports in accordance with Regulation 26 of the Care Home Regulations 2001. Furthermore, anonymous ‘Service User Satisfaction Surveys’ or ‘Relative Screening’ forms had been distributed to residents and / or their representatives every three to four months. Questionnaires returned were available for inspection however they did not provide details of the date the survey had been completed. Likewise, the date of the survey had not been recorded on the summary score sheet for the benefit of interested parties to view. This was discussed with the manager during the visit. A suggestion box had been sited in the reception area of the home to encourage residents to share their views privately. One residents’ meeting had taken place since the last visit and minutes had been developed in large print. Pre-inspection records detailed that the manager did not act as an appointee for any of the people living in the home. The manager reported that all the residents looked after their financial affairs independently or with support from family members or personal representatives. The organisations head office was responsible for invoicing and administering fees. At the time of the visit, the manager looked after the personal spending money for two residents. Staff were clear about the procedures in the home for managing residents’ monies and records viewed had been correctly completed to account for money handled on behalf of residents. The home had a ‘Health and Safety Policy and Procedure in place. Preinspection records detailed that maintenance and associated records were available and up-to-date for all key areas. Examination of records revealed that the home did not have an up-to-date certificate for the electrical wiring installation in the home. The manager produced a copy of a purchase order for work carried out on the electrical wiring system within the home, however a certificate was not available to confirm the wiring installation in the home was safe and complied with the necessary Regulations. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 24 Since the last inspection, the home had made arrangements to have the fire alarm and gas installation serviced and certificates had been obtained to confirm the installations were maintained to a satisfactory standard. The home had also completed monthly records of the hot water temperature outlets, to confirm they were appropriately regulated. Fire records were viewed during the visit. Records showed that the fire alarm system and extinguishers had been routinely serviced. Records also confirmed that the fire alarm system had been tested on a weekly basis and that monthly visual checks of the fire extinguishers and testing of the emergency lighting had been undertaken. A basic fire risk assessment had been completed and staff had received fire instruction training. Some gaps in safe working practice training were noted. Please refer to the previous section (Standard 30). Woodlands Manor DS0000064444.V341688.R02.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must include information on all the needs of the residents and the level of intervention required to meet their needs, to safeguard the welfare of the people using the service. An up-to-date electrical wiring certificate must be obtained and a copy forwarded to the Commission for Social Care inspection, to confirm the electrical wiring installation is safe. Timescale for action 16/07/07 2. OP38 13(2) 16/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The home should continue to develop the social activities programme in accordance with current literature and best practice, to ensure the recreational needs of residents with DS0000064444.V341688.R02.S.doc Version 5.2 Page 27 Woodlands Manor 2 3 4 5 6 7 8 OP16 OP18 OP19 OP19 OP30 OP31 OP33 cognitive impairments are fully considered. Details of the outcome of complaints should be shared with complainants and recorded, so that people know their complaints and concerns have been acted upon. All staff should complete formal training in the Protection of Vulnerable Adults, so that they understand how to recognise and respond to suspicion or evidence of abuse. Arrangements should be made to repair or replace the damaged carpet on the 1st floor landing as a matter of priority, to prevent an accident from occurring. The dampness in the hairdressing salon should be repaired and the room redecorated, to ensure the room is well maintained for residents. The home’s training matrix should be updated and include details of Infection Control Training, to enable an accurate assessment of the outstanding training needs of staff. The manager should complete a National Vocational Qualification in Care at level 4 or equivalent, to ensure she has the necessary qualifications for her role. The date / period of the home’s quality assurance audit should be included on the summary record and questionnaires for reference. Woodlands Manor DS0000064444.V341688.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Manor DS0000064444.V341688.R02.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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