Inspection on 05/10/06 for Woodlands Manor

This inspection was carried out on 5th October 2006.

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

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

Other inspections for this house

Woodlands Manor 04/06/07

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 5th October 2006 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.V297882.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 DS0000064444.V297882.R01.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) 017045544848 Woodlands Manor Ltd Miss Lyndsey Emma Dee 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.V297882.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 23rd January 2006 3. 4. 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 three levels. 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 £311.00 to £415.00 per week. Woodlands Manor DS0000064444.V297882.R01.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 a total of 9 hours. Nineteen 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 owner, registered manager, four staff members, seven residents and a relative were spoken to during the visit. Furthermore, satisfaction survey forms “Have your say about…” were distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional views / feedback about the home. All the core standards were reviewed and previous requirements and recommendations from the last inspection in January 2006 were discussed. What the service does well: Overall, feedback received from residents and their representatives was complimentary about the quality of care provided at Woodlands Manor. The home had received further investment in order to improve the environment and areas viewed were clean and hygienic. A resident reported; “It’s always beautiful and clean.” Staff were observed to spend time chatting to residents offering support and assistance throughout the day. Feedback received from residents included; “Staff are extremely helpful and courteous” and “I am very pleased with the care received by all staff at Woodlands Manor.” A Statement of Purpose / Service User Handbook and Contract had been produced by the home, to provide prospective residents and /or their representatives with key information on the service. This enabled people to determine if the home was suitable for their needs and expectations. An assessment and care planning system had been established to identify and plan a response to the health, personal and social care needs of residents. Records showed that residents had access to health care practitioners, subject to individual needs and this was confirmed by the people living in the home. For example, a resident stated; “The staff help us to make appointments with doctors and other health people when necessary.” The people living in the home reported that they were generally satisfied with the activities, lifestyle and meals provided in the home. Comments from three residents included; “Activities are organised most days for residents who wish to participate. I’m not very interested in joining in and this is respected”; “I Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 6 can come and go as I please” and “The chef is superb. We get two choices for dinner and tea and the standard of catering is very good.” Records showed that complaints received by the home had been acted upon and residents confirmed that they felt listened to, were aware of who to speak to if they had any problems and how to complain. Quality assurance systems had been developed and the views of residents and their representatives were obtained at regular intervals, to ensure the home was run in the best interests of residents. What has improved since the last inspection? What they could do better: The home did not have suitable register in place to record controlled drugs / medication that required a witness signature. Furthermore, a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain was not in place for staff to reference. The home should address these matters in order to improve record keeping and ensure best practice. Although good progress had been made in supporting staff to complete training in Safe Working Practice topics, records showed that a number of staff required fire safety and food hygiene training. This must be addressed to confirm staff are appropriately trained for their jobs. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 7 Only four staff had completed training in the Protection of Vulnerable Adults and some staff lacked awareness of how to recognise and respond to suspicion or evidence of abuse. Arrangements should be made to ensure all staff receive training in this subject as a matter of priority in order to safeguard the welfare of the people using the service. Overall recruitment practice was satisfactory however one member of staff had commenced employment at the home before the results of a Protection of Vulnerable Adult (POVA) check had been completed. Systems should be established to ensure this does not happen again so that residents are fully protected. At the time of the visit the home did not have an up-to-date gas safety or fire alarm service certificate. These certificates must be obtained to confirm the health and safety of the people living in the home is safeguarded. Furthermore, the hot water temperature outlets should be tested on a monthly basis to confirm the temperature is regulated to a safe temperature and risk assessments for food handling should be made available for staff to reference. 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 DS0000064444.V297882.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 DS0000064444.V297882.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, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents had access to a range of information on the home to enable them to make an informed decision about the service provided. Assessments had been completed to ensure the needs of prospective residents were identified before they moved into the home. EVIDENCE: The home had developed a Statement of Purpose / Service User Handbook to provide prospective residents with information on the service provided at Woodlands Manor. Feedback received from residents via Care Home Survey forms and discussion confirmed that the people living in Woodlands Manor or their representatives had received information on the home and had been issued with a Contract. Copies of contracts were available on files viewed. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 10 Two files were examined during the visit for residents who had moved into the home since the last inspection. Each file viewed contained a range of preadmission, health and functional assessment information, which had been completed by senior staff in the home. Advice was given to the manager on how the assessments could be further improved in order respond to the diverse needs of individuals accessing social care services. Copies of social work assessments and care plans were also on file for residents referred via social services. The manager confirmed that information gained from the assessment process was used to develop a plan of care for each resident. Woodlands Manor DS0000064444.V297882.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were in place that detailed residents’ individual needs and the support required to meet them. Overall, medication was well managed and systems were in place monitor all aspects of medication practice. Residents had access to a range of health care services subject to individual needs and care was provided in a manner that satisfied the needs, rights and expectations of residents. EVIDENCE: Two files were viewed for residents who had moved into the home since the last visit. Each file contained a plan of care that provided information on the needs of residents, the support required by staff and the aims of their individual plan. Care plans had been kept under monthly review and separate information on the residents’ views of their care needs had also been obtained. Supporting documentation including; pen pictures, social history information, preferred activities, daily report sheets, accident and weight records, night care plans, relative meetings and moving and handling, pressure sore and falls risk assessments were also available on files viewed. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 12 Records of Health Care Appointments detailed that residents had maintained contact with a range of health care professionals, subject to individual need. The health professionals included; chiropodists, district nurses and general practitioners. Feedback received from service users and their representatives via Care Home Survey forms and through discussion confirmed the people living in the home received the medical support they needed. Comments included; “Staff always organise medical attention as required including eye tests”; “I have been very happy, comfortable and well cared for while I have been at Woodlands Manor” and “The staff help us to make appointments with doctors and other health people when necessary.” The home had developed a medication policy to provide guidance to staff. At the time of the visit, a copy of guidelines issued by the Royal Pharmaceutical Society of Great Britain was not available for reference. The manager reported that none of the residents self-administered their medication. A record of staff trained and authorised to administer medication together with sample signatures and a system to check the identity of residents prior to administering medication had been established. Monthly medication audits were undertaken by the manager and a problem / report file was in place to monitor and identify any issues with medication. The home used a monitored dosage system that was dispensed by a local pharmacist. Medication was stored in a locked medication trolley that was bolted to a wall when not in use. A separate fridge was available to store medication requiring cold storage and temperature records were maintained. Overall, medication systems and administration records checked were maintained to a good standard. There was one instance where the date and amount of a medication received had not been recorded. Furthermore, the manager was advised to obtain a Controlled Drugs Register as the home was using separate sheets of paper to record the administration of Tamazepam. Records were in place to account for medication returned to the pharmacist. Staff spoken with during the inspection showed a good understanding of how to promote and safeguard the social care values of respect, privacy and dignity in their day-to-day practice and confirmed they had received training in this subject as part of their induction. Policies and procedures had also been produced to provide guidance to staff. Staff were observed to be patient, respectful and sensitive to the needs of residents during the visit. Feedback received from residents and their representatives via Care Home Surveys confirmed the people living in the Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 13 home received the care and support they needed. Residents spoken with during the inspection reported that their privacy and dignity was respected. Comments included; “The staff are very good and kind to me”; “Staff are extremely helpful and courteous” and “I am very pleased with the care received by all staff at Woodlands Manor.” Woodlands Manor DS0000064444.V297882.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 and 15 available evidence including a visit to this service. Daily life and activities within the home were flexible and varied to meet the preferred routines and recreational interests of residents. The dietary needs of service users were well catered for, with a balanced and varied selection of food available that met residents’ needs and choices. EVIDENCE: The home had a ‘Social Activities Timetable’ that was displayed in the reception area of the home for residents to view. No changes had been made to the timetable since the last visit. A programme detailed that a minimum of three activities were facilitated each day for residents. The activities included; hairdressing, board and ball games, bingo, quiz, nail care, musical movement and exercise, musical entertainment and nostalgia sessions. Residents spoken with reported that additional activities were also arranged from time-to-time. These included clothes parties, trips and musical entertainers. No ministers of religion visited the home at the time of the inspection. The manager confirmed that arrangements would be made to support residents to observe their religious beliefs, subject to individual need. Three residents Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 15 reported that they visited a local church independently each Sunday and another resident received regular visits from a church visitor. Since the last inspection the manager had established an activities book to record the date of activities and participants. Overall, discussion with residents, feedback from Care Home Surveys and examination of the home’s activity record book confirmed that a range of recreational activities were provided which satisfied the recreational interests and needs of residents. Comments from residents included; “I go to some activities and when it is bingo someone helps me”; “We have a good choice of activities” and “Activities are organised most days for residents who wish to participate. I’m not very interested in joining in and this is respected.” 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 they could receive visitors at any reasonable time and the visitors’ book in reception showed that visitors called at different times of the day. A relative spoken with reported; “I am always made to feel welcome.” The routines in the home appeared to be flexible and determined by the residents. Residents spoken with during the inspection confirmed that they were able to exercise choice and control over their lives and that they could follow their own routines. Rooms viewed had been personalised by residents and contained personal possessions including pictures and ornaments. Comments from residents included; “I am able to get up and go to bed when I want”; “I can come and go as I please” and “I have no restrictions placed on me whatsoever.” Staff spoken with demonstrated an awareness of their duty of care to balance rights, risks and responsibilities in order to safeguard the people living in the home. Staff were observed to offer practical and emotional support to residents throughout the day and were sensitive to the different needs of residents. Woodlands Manor had developed a four-week menu. A copy of the menu was displayed on the home’s dining room notice board. Examination of the menus and discussion with the residents confirmed that residents had a choice of meals and that they received a nutritious, balanced and wholesome diet. One resident spoken with reported that the home provided a special diet for health reasons and the cook confirmed that the home was able to cater for religious or cultural dietary needs as requested. The kitchen was viewed during the inspection and was found to be clean and well organised. Records of meal choices and temperature checks were examined and found to be in good order. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 16 Meals were served in the home’s dining room at set times. The dining room was pleasantly decorated and furnished. Tables were set with menu cards, tablecloths, napkins, condiments and fresh flowers. The manager reported that meal times were flexible and that alternative arrangements could be made in order to accommodate individual needs. Additional drinks were served throughout the day and residents were able to eat their meals in their rooms if they wished. Feedback received from residents via Care Home Survey forms and through discussion confirmed that residents enjoyed their meals. Comments included; “The food is excellent”; “The chef is superb. We get two choices for dinner and tea and the standard of catering is very good” and “I am very satisfied with the food provided.” Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living in the home were satisfied with the service provided and were confident that if they made a complaint their views would be listened to and acted upon. Some staff lacked awareness of the different types of abuse and how to respond to suspicion or evidence of abuse. EVIDENCE: Woodlands Manor had developed a ‘Complaints, Suggestions and Compliments Policy’, a copy of which was displayed on the home’s notice board. Details of ‘Making a Complaint and Giving Compliments’ had also been included in the home’s Service User Handbook. Residents confirmed via care home surveys and through discussion that they felt listened to, were aware of who to speak to if they were not happy and how to make a complaint. None of the residents spoken with during the inspection had any complaints or concerns about the service. The home’s record of complaints was viewed. This showed that three complaints / concerns had been received since the last inspection. Each complaint / concern had been appropriately documented and confirmed that the manager had responded promptly to the issues raised. Five compliments had also been received from relatives, to express their appreciation of the care provided by staff to individual residents. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 18 The home had developed policies and procedures to ensure an appropriate response to suspicion or evidence of abuse. The policies included an ‘Avoidance of Abuse’ and a ‘Whistleblowing’ procedure. Since the last inspection, the home had obtained a copy of the new local authority adult protection procedures for the City of Liverpool and Borough of Sefton. Training records showed that only four senior staff had completed training in the protection of vulnerable adults. The manager reported that additional staff were due to complete the training during November 2006 and that a number of staff had covered the subject as part of their National Vocational Qualification training. Staff spoken with during the visit demonstrated different levels of understanding regarding the various types of abuse and reporting procedures. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 19 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, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and had continued to receive ongoing investment in order to improve and maintain the environment for residents. Some hot water outlets had not been fitted with thermostatic valves and risk assessments had not been completed to minimise and control potential risks. EVIDENCE: The main entrance of Woodlands Manor was accessible via a ramp and a call bell system and passenger lift was installed in the home. Handrails were fitted along corridors and residents had access to personal mobility aids, subject to individual needs. A part-time and a full-time handyman were employed who had responsibility for general maintenance and repair. Job sheets had been established to record work in need of attention and a maintenance plan had been developed for the Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 20 period April 2006 to March 2007. Monthly Health and Safety audits had been completed. There was evidence that the home continued to receive ongoing maintenance and refurbishment. Since the last visit, four bedrooms and a front lounge had been redecorated and refurbished and a link corridor had been repainted. Ongoing building work was in process on the top floor in order to develop some new bedrooms. Areas within the home appeared to be well maintained and the external grounds were tidy and attractive. The manager reported that all radiators had been fitted with guards however pre-set thermostatic water valves had not been fitted in some areas of the home and risk assessments had not been completed to address the risks. This was discussed with the owner and manager during the visit. The home employed three domestic staff. All areas viewed were clean and fresh. Infection control policies and procedures and Control of Substances Hazardous to Health data sheets were available for staff to reference. Records showed that the majority of staff had completed infection control training. Residents spoken with confirmed the home was kept clean and tidy. Comments included; “The home is very clean and fresh smelling”; “Everywhere looks lovely. My room is very nice”; “The cleaners work hard to keep our home clean” and “It’s always beautiful and clean.” The laundry was sited in the basement and was equipped with a washer, drier and individual baskets to store each residents clothing. Staff were provided with protective clothing and hand washing facilities. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff were deployed to meet the needs of the people living in the home. The welfare of residents was generally protected and safeguarded through the home’s recruitment procedures and practices. Staff had access to training opportunities to ensure competency in their role however some staff had not completed training in all safe working practice topics. EVIDENCE: Inspection of rotas, direct observation and discussion with the manager, staff and residents confirmed that a minimum of one senior and two carers were on duty 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. Feedback received from residents via care home surveys and through discussion confirmed that staff were available when needed and that they received the care and support they required. Residents spoken with complimented the staff. Comments included; “The staff are very good and kind to me” and “All the staff and management seem very friendly, helpful and efficient.” Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 22 The manager reported that the home employed 12 care staff. Training records showed that 8 staff (66.66 ) had completed a National Vocational Qualification (NVQ) at level 2 or above in Care. A further two staff were working towards the award. The home had a Recruitment and an Equal Opportunities Policy and Procedure in place. Pre-inspection records detailed that three new staff had commenced employment at the home since the last inspection. All three files were viewed. Personnel files contained application forms, two written references, health declarations, proof of identity, terms and conditions, job descriptions and Criminal Record Bureau checks. Records highlighted that one member of staff had started employment approximately two months before a Protection of Vulnerable Adult (POVA) check had been received. The manager and owner reported that this was not general practice and that an oversight had occurred. Each new employee had completed an in-house induction that was based upon the specification of the National Training Organisation. The home’s training records / matrix showed that staff had access to a wide range of training that was relevant to their role and responsibilities. Since the last inspection ten staff, including the manager, had completed dementia awareness training. Furthermore, a number of staff had completed fire training, first aid, health and safety, food hygiene, infection control, care skills, National Vocational Qualification, optical awareness, risk assessment and medication training. Records showed that a number of staff required fire safety and food hygiene training. The Organisation’s ‘Training Coordinator’ had established a system to monitor and prioritise the outstanding learning needs of staff and both these topics had been marked as ‘priority’. No date had been allocated. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure residents and their representatives were consulted about the service, to ensure the home was run in the best interests of residents. Systems had been established to safeguard residents’ finances. Some important records were not in place, to verify that the health, safety and welfare of residents was safeguarded. EVIDENCE: The manager, Miss Lyndsey Dee, was registered with the Commission for Social Care Inspection and had managed the home since approximately June 2005. Prior to her appointment, Miss Dee had gained experience as a deputy manager in another home within the Cedars Care Group. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 24 Since the last inspection, the manager had enrolled and started to work towards the National Vocational Qualification (NVQ) level 4 Registered Managers Award. The manager had previously completed a NVQ level 4 in Management. Training records showed that the manager had completed a range of training that was relevant to the management of a residential care home for older people with dementia care needs and all safe working practice training was upto-date. Staff and residents spoken with during the visit complimented the manager and confirmed that she was approachable, communicated a clear sense of direction and was supportive in her role. The manager was observed to offer support and guidance to staff and residents throughout the day. The owner commissioned an external consultant to undertake a quality assurance assessment. This had last been completed during October 2005. The home had also developed a ‘Service User Satisfaction Survey Policy and Procedure’, which involved distributing a questionnaire to residents and / or their representatives every three to four months. Summary records were completed and displayed on the home’s notice board to view. A suggestion box was also in place, to encourage residents to share their views privately. Discussion with residents and staff confirmed that residents and staff meetings had been coordinated on a regular basis. Minutes of the meetings were available to view. The home had a ‘Service User Finances Policy and Procedure’ in place. Preinspection records detailed that the manager acted as an appointee for one resident. The manager reported that all the other residents looked after their financial affairs independently or with support from family members or solicitors. 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 five residents. Two of the five records were viewed during the visit. Personal monies were not pooled and appropriate records and receipts were in place. Balances checked were correct. Woodlands Manor had a ‘Health and Safety Policy and Procedure in place. Preinspection records detailed that maintenance and associated records were available for all key areas however an up-to-date certificate for gas safety and the fire alarm system could not be located. Furthermore, no checks on the water temperature had not been carried out in the home and risk assessments for food handling could not be located. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 25 Fire records were viewed during the visit. Records showed that the fire alarm system was checked on a weekly basis and that monthly visual checks on the fire extinguishers and emergency lighting had been undertaken. Training records showed that day and night staff had received fire instruction training at appropriate intervals. A fire risk assessment had been completed during January 2006 and the manager confirmed she was aware of the new fire safety risk assessment requirements for residential care premises. Some staff had not completed all safe working practice training as identified in Standard 30. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 2 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.V297882.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP30 Regulation 18 Requirement Safe practice training must be completed by all staff and refresher training must be completed periodically. [Previous timescale of 10/12/05 not met]. An up-to-date gas safety and fire alarm service certificate must be obtained and a copy forwarded to the Commission for Social Care inspection. Timescale for action 05/01/07 2 OP38 13(2) 05/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP9 Good Practice Recommendations Suitable storage and recording systems for controlled medication should be established. A copy of ‘The Administration and Control of Medicines in Care Homes and Children’s Services’ (issued by the Royal Pharmaceutical Society of Great Britain) should be obtained for reference. All staff should completed training in the Protection of Vulnerable Adults. DS0000064444.V297882.R01.S.doc Version 5.2 Page 28 3 OP18 Woodlands Manor 4 OP25 5 OP29 6. 7 OP38 OP38 The absence of pre-set thermostatic valves should be risk assessed for each service user. Planned installation work should be prioritised according to the level of risk identified. Systems should be established to ensure staff do not start working in the home prior to receiving a satisfactory Protection of Vulnerable Check or Criminal Record Bureau certificate. The hot water temperature outlets should be tested on a monthly basis. Risk assessments for food handling / hazardous analysis critical control points should be available for staff reference. Woodlands Manor DS0000064444.V297882.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 DS0000064444.V297882.R01.S.doc Version 5.2 Page 30 - 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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