CARE HOMES FOR OLDER PEOPLE
Woodlands Nursing Home Sands Lane Mirfield West Yorkshire WF14 8HJ Lead Inspector
Sally McSharry Key Unannounced Inspection 2nd November 2006 09:00 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 Nursing Home DS0000001100.V319032.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 Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Woodlands Nursing Home Address Sands Lane Mirfield West Yorkshire WF14 8HJ 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) 01924 491570 01924 497377 Woodlands.Mirfield@Craegmoor.co.uk Speciality Care (REIT Homes) Limited Care Home 87 Category(ies) of Dementia - over 65 years of age (87), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (87) Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Can provide accommodation and care for 5 named service users under 65 years of age. 31st May 2006 Date of last inspection Brief Description of the Service: Woodlands Nursing Home provides nursing, personal care and accommodation for up to 87 older people who suffer from dementia type illnesses and mental disorders. Woodlands is a large, brick built home set within 47 acres of woodland. The home is divided into 4 units over two floors. Access to the first floor is gained via a passenger lift. The home provides single and double room accommodation. Some rooms have en-suite facilities; some rooms have a small cubicle which is fitted with louvre doors; the cubicle contains a toilet. The home is in a secluded position, one mile from public transport but has a minibus available. Woodlands has its own gardens that includes patio areas, seating, an orchard and a pond. Some outside areas are securely fenced to allow freedom to walk or sit in a protected setting. The provider informed the Commission for Social Care Inspection on 10 May 2006 that fees range from £344.71 to £596.29 per week. Additional charges include hairdressing, private chiropody, newspapers, special toiletries, tobacco and some clothing. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home carried out by two inspectors over two days. The inspectors arrived at the home at 8:50 am on 2 November 2006 and, over that day and the following day, spent 13 hours in the home. During this visit the inspectors spoke to some of the service users, visiting relatives, some of the staff and the home’s management. The acting manager was not available, however the Deputy Manager, Mr Mohammed, and the Area Manager, Ms Elizabeth Slight, assisted the inspectors. The inspectors read care records, audited a sample of medications, reviewed staff recruitment and training records, carried out a brief tour of the building and observed breakfast and lunch being served in the home. Prior to the inspection, twenty service user questionnaires were sent to Woodlands Home to obtain service users’ views about living at the home. One completed questionnaire was returned. Some service users in the home are very frail and would not be able to complete a questionnaire. There were seventy two service users resident in the home on the day of this visit. Relative surveys were sent out to twenty of the service users’ relatives or friends. When writing this report, twelve of the relatives had responded. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider, information about three complaints investigated by the provider. The registered provider and acting manager failed to return the pre inspection questionnaire sent out by the Commission requesting information about the home. The inspector collected a partially completed questionnaire on the first day of the visit. On the first day of the visit the inspectors identified three areas of concern. These were the shortage of staff at the home, the lack of activities being offered to service users and the fire safety precautions at the home which had been seriously compromised by work carried out in the home on the air conditioning and ceiling tiles. The inspector felt these issues were serious and could not wait for the inspection report to be produced; CSCI therefore wrote to the registered provider on 3 November 2006 asking for action to be taken quickly regarding these issues. The inspector would like to take this opportunity to thank everyone who participated in the inspection process.
Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better:
Since the last inspection the number of staff employed at Woodlands Care home has fallen. There is insufficient staff employed to cover the care shifts. This means, at times, staff have to work extra shifts or that there are not enough staff on duty. This has been commented on by relatives visiting the home and must be addressed by the company. There is a lack of meaningful activities and stimulation provided in the home. Some service users said that they were bored and relatives commented about the lack of stimulation in written feedback provided for the inspection. Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 7 More could be done to support service users’ privacy and dignity by ensuring personal information is not publicly displayed in the home. Some service users receive good support to maintain their cultural and spiritual needs, however not all service users received this support. Efforts must be made to maintain service users’ spirituality because some service users are no longer able to do this due to their illness. Internally and externally the building is deteriorating. Due to a lawn mower breaking down, and no alternative arrangements being made, the exterior of the building is overgrown and neglected. This means service users are unable to safely walk on the grassed areas in front of the home as the long grass is hazardous. Some of the external window frames are in poor repair. This has been identified in inspection reports since October 2005. Some redecoration has taken place. However, this is not keeping pace with the wear and tear the building receives. Some areas are shabby, some bedrooms have not been redecorated for many years. Bedding in the home is thin, worn and a dingy peach/grey colour and must be replaced. The standard of bathing facilities in the home is now very poor. Bathrooms and toilets are cold; they do not have curtains fitted to the windows. Some of the baths are not suitable for the service users to use. Others are worn, cracked and must be replaced. The home has not had a registered manager for over twelve months and the company must address the lack of a permanent manager. Quality assurance measures put in place by the company are ineffective. Systems have been audited and problems identified however nothing has been done to address the issues identified. A management visit is carried out monthly and a report produced. However, these visits and the resulting report fail to identify many of the issues seen at this visit or identified by relatives in the questionnaires returned to the Commission. The company must implement an effective quality assurance programme that takes into account the opinions of the service users and their relatives and friends. Individual service users’ finances are easier to access on the computer and the records are simpler to understand. However, it is still not clear if the money that Craegmoor holds for service users earns any interest for the service users. In some cases, where service users have been resident at the home for many years, they have deposited considerable amounts of money and this should be earning interest for the service user.
Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 8 General health and safety precautions and checks are being carried out at the home. However, during the first day of the visit a fire safety officer from West Yorkshire Fire Safety Team was also at the home. He advised that work carried out on the home’s air conditions system and ceiling had seriously compromised the fire safety precautions in the home. The company must address this. 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 Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 9 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 Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No service user moves into the home without having had their needs assessed and been assured their needs can be met. EVIDENCE: Service users’ records clearly showed that, before any service user is admitted to the home, a detailed pre-admission assessment is carried out. A qualified member of the staff visits the prospective service user to carry out this assessment. Service users’ records also included copies of the Community Care Assessment and Easy Care Document (assessment documents completed by other health care professionals either in the community or in hospital). The accumulated information is good and provides the staff at the home with some idea of the service users’ needs before admission and helps the staff to prepare for the service users’ admission to the home.
Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 11 The home employs staff from a varied cultural background and, since the last inspection, some service users from differing cultural backgrounds have been admitted to the home. Consideration has been given to the spiritual and cultural needs of these service users before they have been admitted to Woodlands. Woodlands do not currently provide intermediate care. Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 12 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. Service users’ health, personal and social care needs are set out in an individual plan of care. Suitable risk assessments are carried out and monitored. Service users are able to make decisions about lives with the support of staff. Medications are managed safely. Service users are treated with respect; their privacy and dignity is not being fully maintained by the staff in the home. EVIDENCE: The standard of care planning has increased considerably, especially on Calder Unit. Two care plans were audited from each unit. The standard varied from unit to unit. However, in general, care records provided the information
Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 13 needed to appropriately care for the individual service users, and reflected individual service users’ cultural and spiritual needs. Health care assessments are carried out monthly and, where they indicate, specialist advice is obtained. Care records demonstrated that staff work to ensure service users assess NHS health care services and support. Some care records on Hopton and Mirfield units have a lot of information in them. This is because some of the service users on these units have been resident at the home for many years. However, some of the records are confusing and it is difficult to tell what information is current. This was discussed with the Deputy Manager and it was recommended that these care plans be re written. Written feedback received from three relatives confirmed that, generally, the standard of care has improved in the home. One respondent said, “For most of the time, I am satisfied with the overall care provided to my father and do feel that this has improved over time. I remain impressed with the professionalism and nursing skills of the manager on my father’s unit.” Eleven of the relatives responding in questionnaires said they were satisfied with the care provided in the home, one said they were sometimes satisfied with the care. A sample of medications was audited on each unit. Those medications audited were correct. Records were clear and complete and staff, when asked, had a good understanding of the medications policy and procedure. During the visit, members of staff worked well with service users, maintaining service users’ dignity and respecting and maintaining their privacy. Service users and relatives, both in written feedback and during the visit, said that staff were very good and caring. Some respondents gave praise to specific members of staff. One relative wrote, “Woodlands has some very caring staff” another relatives stated, “The staff do a magnificent job who care for my mother at Woodlands. I cannot thank all these people enough.” On one unit staff had made a list of the service users and which rooms they occupied. However, this list also included personal and private information about the service users. When the inspectors brought this to the attention of the staff, the list was removed immediately. It is recommended in this report that further training and supervision be provided to staff to ensure that, at all times, service users’ privacy and dignity is maintained. Woodlands Nursing Home DS0000001100.V319032.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ social, cultural, religious and recreational needs are not being met. They are helped to maintain contact with their families and the local community. Service users are able to exercise some choice and control over their lives. Meals provided are varied. Meals are served in a pleasant environment and service users who need support receive the assistance they require. EVIDENCE: Although the home employs one fulltime activities organiser, there was little or no evidence of regular organised activities in the home. Service users said they were bored. Relatives commented in written feedback about the lack of stimulation and activities for service users in the home. At the time of the visits, there were no plans in the home to mark Bonfire Night or Remembrance Sunday. Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 15 Service users on Calder Unit said that one member of staff regularly plays the organ for them, something that the service users really enjoy. It is a requirement of this report that all service users have access to activities in the home. Several relative questionnaires said that the TV reception at the home is very poor. Service users and the inspectors confirmed this during the visit. It is recommended action is taken to address this. Care plans recognise service users’ spiritual needs, however little has been organised to meet these needs on a regular basis. Staff support some service users with spiritual needs and it was reported that one Anglican minister has recently visited the home. However, it is recommended further work be carried out to ensure all service users’ cultural and spiritual needs are met. Woodlands care home is located a mile from public transport, however the home has a minibus available to help visitors get to the home. Eleven relatives who returned questionnaires said that they were made to feel welcome at the home. One said that they were “sometimes” made welcome. Care records report that some choice is offered to service users, however not all service users in the home were able to confirm this because of their frailty. Staff were seen offering service users some choices, for example where they wished to spend the day and what they wanted for their meals. However, some routines in the home have begun to restrict service users’ choices. At certain times of the day, service users are offered tea or coffee, at other times only juice is offered. The inspector discussed with the deputy manager having hot and cold drinks available at all times, so giving the service users a full choice. Feedback on the days of the visit regarding meals served at the home was generally good. There is a choice available at each meal and service users who were able to comment said that the meals were “good”, “alright”. The inspectors observed breakfast and lunch being served. The meals looked appetising and staff were attentive when serving meals giving assistance and support to service users when needed. The one service user questionnaire returned said they usually enjoyed the meals. One relative, in feedback, said that at times sandwiches prepared for the service users’ supper are not always stored in the refrigerator. This should be investigated and monitored by the registered provider. Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are confident to make complaints and that these will be listened to and taken seriously. Service users are protected from abuse. EVIDENCE: Since the last inspection the acting manager has put in place a file in which all formal complaints made about the home are recorded. Details include the investigation carried out, the result of the complaint and any action taken. The home’s complaints procedure is displayed in the entrance of the home and in the home’s statement of Purpose and Service User Guide. Nine of the 12 relatives responding in the questionnaire said they knew how to make a complaint. At the last inspection it was made a requirement in the report that all staff receive training about adult protection and the prevention and reporting of abuse. Records show that all but five staff in the home have received this training and that further training sessions are scheduled to take place in Woodlands in November 2006. The registered provider should ensure the five staff that have not yet attended adult protection training attend in November. Woodlands Nursing Home DS0000001100.V319032.R01.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, 21, 24, 25 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users do not live in a safe, well-maintained environment. The home is not always clean, pleasant and hygienic. EVIDENCE: During the visit, and in significant written feedback from relatives, it is clear the standard of accommodation and facilities in the home have declined and, in some areas, are very poor. Requirements made in the last inspection report about the replacement of window frames in poor repair and the bath and toilet facilities have not been fully met. Relatives expressed dissatisfaction about the floor covering on the corridors which smell unpleasant, even when cleaned. The acting manager has discussed
Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 18 plans to replace the flooring in these areas with hard non-slip floor. These discussions took place some months ago, however Craegmoor have failed to provide the funds needed to do this work. Over the last two years, the acting manager has advised that work to replace window frames in poor repair has been surveyed and that quotes were awaited to do the work. However, during this visit the inspectors were again advised that surveys were going to be carried out for this work. The standard of cleanliness in toilet and bathroom facilities has improved, however the bathing facilities have deteriorated. The specialist Parker baths are in poor repair, cracking and wearing of the baths is evident. Some of the cracking and wearing to the bath surfaces means the bath cannot be effectively clean and therefore is a potential infection control risk. Other bathrooms have low baths which are inappropriate for use. Many bathrooms still do not have curtains or blinds at the windows. A sink was seen with no tap top. Suitable and safe bathing facilities must be provided to meet the needs of the service users. General décor in the home is deteriorating and, although some rooms have been redecorated, the rate of redecoration is not keeping pace with the wear in communal rooms and bedrooms. Bed linen is, at best, thin, poor quality, faded and a dirty grey/peach colour. Some bedrooms, although double room accommodation, are used as single rooms. In some of these rooms, the second unused bed is stripped bare. In other cases there is just a bed base. This is unpleasant for the service user occupying the room and shows a lack of maintenance and interest by the staff. Surplus beds should either be removed and stored appropriately or made up with clean linen. Although not a wide spread problem, unpleasant odours were noted in some bedrooms and on the main corridor areas on Calder and Thornhill Units. Efforts should be made to remove and manage unpleasant odours in the home. Some areas of the home were noted to be cold. The deputy manager advised that bedroom windows are open to allow fresh air in them and that staff close the windows before service users return to their rooms. One relative made specific mention in the questionnaire that, in their opinion, rooms are cold. Care must be taken to ensure all service user areas in the home are sufficiently warm. The exterior of the home, whilst in some areas is generally cleaner, needs tidying up. The home’s lawnmower broke down some time ago and the lawn
Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 19 areas are overgrown and dangerous to walk in. The exterior of the home must be maintained and safe for service users to use. Woodlands Nursing Home DS0000001100.V319032.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Insufficient numbers of staff are employed. The staff receive induction and foundation training and are competent to work in the home. Staff recruitment policies and records protect service users. EVIDENCE: Since the last inspection the number of staff employed has fallen and insufficient new staff have been recruited. Therefore there are insufficient staff employed to cover care shifts in the home. The duty rota shows that some staff are working excessive numbers of 12 hour shifts and that, on some occasions, the home has run with insufficient numbers of staff to appropriately and safely provide care. The registered provider has reduced the number of night staff on duty. Although the home is not full and there are service user vacancies, the vacancies are not on one unit therefore it is not safe to reduce staffing numbers on any particular unit.
Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 21 A lack of activity coordinator hours has already been mentioned in this report in the section relating to “Daily Life and Social Activities”. Six relatives commented on staff shortages in questionnaires. One stated, “Staff are often over stretched and asked to work extra hours even after working double shifts. This can only be detrimental to the health of the staff and lead to residents not receiving that extra special care they deserve.” Another commented, “ I do not consider there to be sufficient in the nursing home during the evening and through the night. I have recently voiced concerns about this situation. In the event of an emergency, I do not believe that there would be sufficient staff to assist residents to evacuate the building. I have also noted during the last few weeks that there have been low levels of staff during the day.” The registered provider must review and increase staffing levels both during the day and at night to ensure there are sufficient numbers of staff on duty to meet the needs of the service users. Since the last inspection, training has continued in the home. A sample of four members of staffs’ training records was checked. These showed that staff have received a variety of training sessions relating to work in the care home and includes mandatory fire and movement and handling training. Training planned in the next few months includes venepuncture (the taking of blood samples), basic food hygiene, health and safety and COSHH (the control of substances hazardous to health), moving and handling people and adult abuse/POVA (the protection of vulnerable adults). Twelve staff in the home have NVQ (National Vocational Qualification) level 2 training or above and a further four staff are working toward the award. This currently gives the home 41 of the care staff with NVQ level 2. The recommended level is 50 and work should continue to obtain this level of training. The recruitment records of four members of staff were checked and an improvement in the standard was noted. Records held the required information and appropriate check and references had been obtained. Woodlands Nursing Home DS0000001100.V319032.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no registered manager at the home and the home is not currently being run in the best interest of the service users. Service users’ financial interests are safeguarded. Staff are not appropriately supervised. The health, safety and welfare of service users and staff is not promoted and protected. Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 23 EVIDENCE: There has not been a registered manager at the home for over a year. The current acting manager has failed submit an application form to the Commission for Social Care Inspection. The registered provider must put forward a suitably qualified and skilled person of good character to manage the care home. Although some audits have been carried out at the home and regular management visits and reports are produced as required under Regulation 26 or the Care Homes Regulations 2001, Regulation 26 reports fail to identify the major issues identified in this report and, therefore, the inspectors question the effectiveness of these management visits. Audits carried out internally in the home have identified some of the issues but then have failed to develop any action plan to address these. Effective quality audit systems must be implemented to monitor and maintain standards in the care home. New computerised financial records have been implemented. These were audited on the computer. They showed deposits made and money spent on the service users’ behalf including what was purchased. Some service users have accrued quite large amounts of savings. There was no evidence to show that the Craegmoor account in which the money is held for service users is earning any interest on behalf of the service user. The company must notify the Commission of what arrangements are in place regarding service users receiving the interest earned on money held by Craegmoor. Some small cash amounts are held at the home for service users. This money was audited and found to be correct. This money is safely and securely held. It was recommended at the last inspection that staff receive formal supervision. This recommendation has not been implemented. Staff advised that they do not receive any formal supervision. Therefore this recommendation is repeated in this report. Records at the home showed that regular checks and tests have been carried out on the equipment in the home. Weekly fire alarm tests have been done and fire drills carried out. During the first day of the visit, the inspectors met with one of the West Yorkshire Fire Safety officers who was also visiting the home. He advised that, following work carried out on the air conditioning system and ceiling tiles, the fire safety precautions in the home had been compromised. This is a serious breach of fire safety. Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 24 The company was contacted by separate letter on 3 November 2006 and asked to provide written confirmation of the action to be taken to address this. Woodlands Nursing Home DS0000001100.V319032.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 3 X X X X N/A 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 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X 1 X X 1 1 1 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 2 X 1 Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 26 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. 2. Standard OP12 OP19 Regulation 16(n)(m) 23 (2) Requirement All service users must have access to daily activities which meet their individual needs. The window frames that are in poor repair must be replaced. Timescale of 30/04/06 and 31/10/06 not met. The exterior of the home must be maintained, kept tidy and safe for service users to use. All areas in the home must be audited and a redecoration programme implemented to keeping pace with the wear in communal rooms and bedrooms. Toilet and bathing facilities and practice in the home must be reviewed to ensure areas are clean, well maintained and adequately equipped. To ensure service users can be adequately bathed in pleasant and hygienic facilities with the risk of cross infection eliminated as far as possible. Timescale of 31/07/06 not met. Timescale for action 13/11/06 28/02/07 3. OP19 23 (2)(o) 31/12/06 4. OP19 23 30/11/06 5. OP21 OP26 23(2)(n) 28/02/07 Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 27 6. 7. OP24 OP24 16 (2) (c) 23 (2) (e & f) 23 8. OP25 New suitable bed linen must be provided. Surplus beds must either be removed and stored appropriately or made up with clean linen. Care must be taken to ensure all service user areas in the home are sufficiently warm. The registered provider must review and increase staffing levels both during the day and at night to ensure there are sufficient numbers of staff on duty to meet the needs of the service users. The registered provider must put forward a suitably qualified and skilled person of good character to manage the care home. 30/11/06 30/11/06 30/11/06 9. OP27 18 (1) 13/11/06 10. OP31 9 31/12/06 11. OP33 12. OP35 10, 12, 15 Effective quality audit systems and 24. must be implemented to maintain and monitor standards in the care home. 12 and 20 The company must notify the Commission of what arrangements are in place regarding service users receiving the interest earned on money held by Craegmoor. 23 (4) During the visit the inspectors met with one of the West Yorkshire Fire Safety officers who was also visiting the home. He advised that following work carried out on the air conditioning system and ceiling tiles the fire safety precautions in the home had been compromised. Craegmoor was contacted by separate letter on the 3 November 2006 and asked to provide written confirmation of
DS0000001100.V319032.R01.S.doc 30/11/06 30/11/06 13. OP38 20/11/06 Woodlands Nursing Home Version 5.2 Page 28 the action to be taken to address this. 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 OP7 Good Practice Recommendations The care plans of service users who have been resident in the home for more than two years should be re written to ensure information is relevant and easily accessible in the care plan. It is recommended that further training and supervision be provided to staff to ensure that at all times service users’ privacy and dignity is maintained. All service users’ spiritual needs should be met and efforts should be made to increase the amount of spiritual support in the home. Action should be taken to improve the TV reception in the home. Staff in the home should at all time maximise autonomy and choice in the home for service users. Hot and cold drinks should be on offer at all times. The registered provider should monitor and ensure the sandwiches that are prepared for the service users’ supper are appropriately stored. The redecoration programme should be continued and address all bedrooms and bathrooms. All parts of the home should be free from unpleasant odours. Training should continue with the aim being for the home to have 50 of its staff trained to NVQ level 2 or above. Staff should receive formal supervision. 2. 3. 4. 5. 6. 7. 8. 9. 10. OP10 OP12 OP12 OP14 OP15 OP19 OP26 OP28 OP36 Woodlands Nursing Home DS0000001100.V319032.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Office St Pauls House 23 Park Square (South) Leeds LS1 2ND 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
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