Inspection on 31/03/08 for Woodlands Nursing Home

This inspection was carried out on 31st March 2008.

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

The inspector 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 Nursing Home 18/09/07

Woodlands Nursing Home 01/05/07

Woodlands Nursing Home 02/11/06

Woodlands Nursing Home 31/05/06

Woodlands Nursing Home 19/10/05

Woodlands Nursing Home 29/04/05

Woodlands Nursing Home 10/02/05

Woodlands Nursing Home 17/09/04

Woodlands Nursing Home 08/04/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Sands Lane Mirfield West Yorkshire WF14 8HJ Lead Inspector Sally McSharry Key Unannounced Inspection 31st March and 15 April 2008 18:30 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.V362053.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.V362053.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 www.craegmoor.co.uk Speciality Care (REIT Homes) Ltd Position Vacant 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.V362053.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. 6th December 2007 Date of last inspection Brief Description of the Service: Woodlands Nursing Home is owned by Speciality Care (REIT Homes) Limited which is a wholly owned subsidiary of Craegmoor Healthcare. The home provides nursing and 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. In some rooms this comprises a small cubicle fitted with louvre doors containing 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 15/04/08 that fees range from £344.56 to £767.18 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.V362053.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service has been suspended, as the Commission for Social Care Inspection is taking enforcement action against the company that owns Woodlands Nursing Home. This inspection included two unannounced visits carried out at the home by two inspectors. The first visit started at 18:30pm and took place during the evening of the 31 March 2008. The second visit commenced at 7am on the 15 April 2008. During the second visit a pharmacist accompanied the two inspectors. The pharmacist is a specialist inspector who looks specifically at how the staff in the home manage, record, store and administer medications. Over the two days the inspectors spent 10 hours in the home. The last key inspection was carried out on 18,19, 24 September 2007, serious concerns about the standard of care provided at that time were identified and following this the Commission for Social Care Inspection has taken legal action against the home. Since September a series of random unannounced visits have been carried out at Woodlands to monitor the standard of care provided. These visits took place on 17 October 2007, 29 October 2007, 6 December 2007 and 19 February 2008. During this visit we spoke with some of the people who live at the home, nursing and care staff. One of the inspectors spoke to a relative about the home by telephone. We examined some people’s care records, audited a sample of medications, reviewed staff recruitment records, and looked around the home. The acting manager at the home also completed an annual quality assurance assessment that was requested by CSCI (Commission for Social Care Inspection), which includes information about people who live at the home, the staff that work there, the service provided and any incidents or accidents that have occurred. As part of this inspection surveys were sent out to obtain people’s views of the home. Twent-five surveys were sent out to relatives, nine were returned. Five Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 6 were provided for visiting health care professionals, one was returned. Surveys were also made available to staff working in the home four were returned. Surveys returned by relatives of people living in the home generally acknowledged the improvements made in the home’s environment and the standard of care delivered to people in the home. One person who spoke to us said that things had improved but that there was a lot of work still to do to make sure the whole home was up to standard. This person also said that now improvements had been made the difficult job would be maintaining these standards. We would like to take this opportunity to thank everyone who participated in the inspection process. What the service does well: What has improved since the last inspection? Improvements to care planning have been made and care plans now contain most of the information care staff need to look after people properly. People in the home generally looked well, some had put on weight and they appeared brighter in mood. People are assisted at mealtimes and meals are now offered which respect and maintain people’s preferences and dietary laws. Staff demonstrated they are more aware of people’s cultural and religious needs and are working to meet those needs. Some people were being offered choices and were able to express what they wanted and staff listen and respected those choices. People are able to visit the home and some are helped to visit if they are unable to get to the home, because they do not have their own transport. Relatives are more confident in the management of the home and the improvements being made. They are more confident to raise concerns and that these will be taken seriously and responded to. Improvements are being made to the environment of the home. One unit is being refurbished and new equipment; furnishings and fittings are being provided. Staffing levels are now appropriate for the numbers and need of the people in the home and extra staff are brought in should people’s care needs increase. Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 7 The staff team is becoming more competent and an extensive training programme has been implemented. New staff have been recruited and the use of agency staff has declined. The acting manager and clinical managers are providing a more stable management team, who provide cover for the home seven days a week. Audits, relative and staff meetings are now carried out regularly and the findings acted upon to make improvements to Woodlands. One person said in their returned survey, “ This home is a large care home with capacity of 80 residents. At present the home is having many improvements -much needed- Training has been an issue but is now being implemented. The home is much improved since September 2007”. What they could do better: Further work could be carried out on care planning so that all staff are competent to write and maintain care plans correctly. This will help Woodlands maintain a good standard of care. Care must be taken with the management of medications to ensure all people in the home get the medicines that are prescribed for them. More effort could be made to ensure the people in the home have their hair styled regularly and well by the hairdresser and staff. People’s dignity could be improved by making sure their fingernails are clean and that they have clean chairs to sit on, rather than chairs that smell of stale urine. The quality of life for people in the home could be improved by ensuring that they all have access to daily social activities, things to do that they enjoy. The refurbishment programme commenced on one unit should progress throughout the whole home, improving the environment that has been neglected for so long. Staff training could be developed. Communications between staff could be improved upon. Woodlands should have more care staff with National Vocational Qualifications to help maintain good standard of care for the people in the home. The recruitment process could be improved to make sure no unsuitable staff care for people at Woodlands. A permanent manager must be appointed at Woodlands to help maintain continuity of care at the home. There should be a manager in post who is registered with the commission. More care could be taken to ensure that fire safety equipment is checked weekly and that all the staff including the night staff know what to do and how to evacuate the building in the event of a fire. Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 8 Over all the improvements made at Woodlands must continue and be sustained. 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.V362053.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.V362053.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. EVIDENCE: This standard could not be fully assessed at this visit. Following the last key inspection in September 2007 when serious concerns were identified about the standard of care being provided. Craegmoor voluntarily stopped admission to Woodlands. Since that date there have been no new admissions to the home. Woodlands Nursing Home DS0000001100.V362053.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. EVIDENCE: Since the last key inspection in September 2007, an acting manger and two clinical managers have been recruited to the home. These staff have done a lot of work on care plans. A new person centred care plan has been introduced and throughout a series of random visits carried out to Woodlands the standard of care planning and records has been seen to steadily improve. One person said in their returned survey, “Recent improvements including invitation to help compile patient care plan”. At this visit not all care plans had been updated and put onto the person centred documentation and some issues were identified mainly on the older records, which have yet to be updated: People referred to in care plans as “he” when the person was in fact female. There was conflicting information in care plans, such as one area of the care plan stating someone should have skin care every two hours and else where in the care plan stating it should be given every four hours. Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 12 Non-specific information using words such as “adequate” or “regularly”. These terms are ambiguous and could be interpreted differently by different members of staff leading to inconsistency in care. The use of inappropriate/incorrect terms in daily records, such as “ care rendered” and “Conveen inserted”. These terms are used in daily records, which are legal records; they are inaccurate and imply something other than what is meant. Work should continue on updating care plans and training staff to ensure that care plans give clear and specific information about how people are to be cared for in Woodlands and record accurately what care has been delivered on a daily basis. Improvements made in this area must now be sustained. During this visit we saw that people in the home looked generally well care for. People have put on weight. Members of staff were more attentive towards people in the home. Meal times were generally more organised. People had appropriate pressure relieving equipment, which was working correctly to help prevent people from developing pressure damage. Relatives and friends in surveys confirmed that they are notified if their relative is unwell or if the doctor has visited. People said they were confident that staff would call in a doctor if their relative needed it. Records in the home and conversations with staff supported this, there was evidence of specialist nurses, doctors, speech therapists and chiropodists being involved in peoples care where needed. One person wrote in their returned survey, “ I visit my brother as often as I can, but I am happy knowing that he is being looked after, as the staff are in regular contact with me”. The acting manager did advise of some difficulty registering people at the home with a permanent community doctor (GP). They are always able to get a GP to visit the home, however local GP’s are reluctant to register people at the home on a permanent basis. The home should approach the local Primary Care Trust to resolve this problem. There is a good, detailed policy in the home covering all aspects of medicines management. This means staff have access to up to date information on legal requirements and guidance. The current Medication Administration Records (MAR) were looked at. There is a record of staff authorised to administer medicines. This means it is possible to identify who was involved in administration if a problem or query occurred. All the MAR charts have a photograph of the person. This helps to reduce the risk of medication being given to the wrong person. Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 13 One chart entry for eye drops had the code “G” used to record no administration because there was no stock available. A system must be in place to identify how much stock there is for the person and further supplies ordered in plenty of time. This will prevent the person from being without their medication, which may affect their medical condition. Good records are made when a medication is changed or cancelled. This makes sure that there is an accurate record of any changes or new medicines. The morning medication round was seen. Time was spent with each person and encouragement given to help them take their medication. An audit of current stock and records showed that some medication had been signed for but not given. For example one chart for a liquid medication had records of administration showing 90ml had been given. However only 60ml of the supply had been used. It is important that medication is given as prescribed so that a person’s medical condition is not affected. There was a tube of cream requiring cold storage in the person’s room. The storage requirements for medication must be followed to make sure the medicine is safe to administer. The date of opening of medicines with limited use once opened is recorded. This reduces the risk of medication being used beyond the date recommended by the manufacturer and therefore unsafe to administer. The controlled drugs cabinet and register are suitable for use. The records of controlled drugs destroyed do not always include the quantity. This is needed to provide an accurate audit trail of these drugs. Generally in the home we felt staff are maintaining people’s privacy and dignity better. People in the home were brighter and talked to us more freely. People were dressed nicely and were confident. People who were still in bed were warm and had their nightclothes on as opposed to just underwear as seen in September 2007. There were a couple of issues noticed, one or two people had dirty finger nails, some of the ladies had unstyled hair and some of the chairs in the lounges smelt of stale urine. These issues were raised with the acting manager as they have a poor effect on people’s standard of dignity. Woodlands Nursing Home DS0000001100.V362053.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. EVIDENCE: Since the last key inspection in September 2007 we have seen some effort to improve the amount of social activities offered to people in the home. At random inspection visits in October, December and February we saw that a lot of craft equipment and games had been provided. The acting manager told us that an activities coordinator was starting work and when we visited we saw evidence of people painting, drawing, going out on trips and staff reading to people. On this visit we found that the activities coordinated had not stayed at the home and again they are trying to recruit to this post. Although equipment is still available, little or no evidence was seen that staff are helping or supporting people to use this. The acting manager reported that twenty people are booked to see the musical “Oliver”. On Mirfield Unit we saw staff chatting to people and one member of staff was reading the local newspaper out to people. However on Calder Unit we sat for sometime watching what was happening in the lounge, there were two members of staff talking to two people, the remaining ten people on that unit sat unengaged and withdrawn. We raised some concern about the quality of life for some people when we read in their care records that their activities only consisted of walking about Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 15 the unit and listening to music. One member of staff said in the survey they returned that they felt residents could be offered more activities and a relative wrote, “ It would be nice if trips could be arranged once in a while”. We feel that after an initial improvement the level and quality of activities has slipped and work is required to improve activities and sustain those improvements made. Woodlands and its staff do not impose any restrictions on visiting. The home is slightly isolated and a good distance from the nearest bus route. However people who returned surveys said that they were able to visit and were now made to feel welcome at the home. One person in particular mentioned that the home does offer a mini bus service to pick up visitors if they have no transport and for this they were very grateful. People in the home do have choices and since the visit in September we have seen some improvements in this area. At this visit we saw people who were able, actively being offered choice and independence. One person who loves a cup of tea was encouraged to make a cup when he wanted one. We saw one member of staff serving breakfasts offering people a choice of menu by showing people what was available. This helps people with dementia because they can see the choice and indicate their preference. However we also saw members of staff asking people repeatedly what they wanted and listing several choices. This kind of approach is difficult for someone with dementia because there is too much information given which they may have difficulty interpreting and give an answer to. Some staff still need further training to ensure they understand the difficulties people with dementia have and how best to over come these. Slow progress had been made in recent months with improving meals and how they are served. However at this visit things had further improved. People with specific dietary laws and requirements were being catered for and staff are much more aware of cultural and religious differences that might effect what someone eats. Dining rooms were pleasantly set, with cloths and condiments. Staff support at meal times has increased and mealtimes were more organised. Staff assisted people who required help and support sensitively. These improvements must now be maintained. During mid morning on Calder Unit when drinks were served no biscuits or snacks were immediately available. Only when the acting manager asked staff, were biscuits offered. Members of staff also started offering and giving people hot drinks before getting side tables for them to rest their cups on. This meant people were holding cups of hot tea or coffee, some people tried to put Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 16 them on the floor. This is unsafe practice and may put people at risk of being scalded and does not allow people to drink comfortably or safely. Woodlands Nursing Home DS0000001100.V362053.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. EVIDENCE: In September we found that the homes then manager had not dealt with some complaints. Since then the regional manager Mr Les Smith has been dealing with complaints. People told us in returned surveys that they knew how to make a complaint and these were dealt with appropriately. There is a record kept in the home of all complaints made and the actions taken to resolve issues. One person told us that in the past they would not have raised issues about the home to the management team, as they had no confidence in them dealing with the matter properly. They said they now felt able to raise issues. Staff in the home must continue listening to people in the home and their relatives and friends to ensure they continue with the improvements in this area. Ninety four percent of the staff at Woodlands have now received training in protecting vulnerable people. Staff were more confident about safeguarding vulnerable people and what they should do if they have any concerns. Efforts should continue to train all staff in these safeguarding vulnerable adults. Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25, and 26. EVIDENCE: People live in an adequate environment. It is fair to say a total refurbishment has commenced on Hopton Unit. Here all new floor coverings, ceilings, light fittings, bathing and toileting facilities, nurse call system, en suite facilities, decoration and furnishings are being provided. New windows have replaced those, which were ill fitting, draughty and leaking. New bed linen has been provided. Floor coverings in the other units have been changed and the management of unpleasant odours has improved. All this work is very encouraging, however this level of refurbishment is needed throughout the home to ensure that people have a good standard of accommodation, furnishing and fittings. One relative said in their returned survey, “By and large, the current work, and improving the rooms and lounges, new carpeting etc. have greatly improved Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 19 Woodlands”. Another said, “ There is already a big difference in the standard of the home, since refurbishment begun”. During this visit it was noticed that the chairs in Thornhill and Calder Units smelt unpleasantly of stale urine and something should be done to improve this for the people living in the home. Woodlands Nursing Home DS0000001100.V362053.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 and 30. EVIDENCE: Visits made during the evening, night, early morning and daytime have helped us assess the staff and whether there are sufficient numbers of staff on duty to meet people needs. Duty rotas confirm that there are currently: Unit Hopton Unit Mirfield Unit Thornhill Unit Calder Unit Day time 1 Nurse 1 care staff and 1 agency care staff. 1 Nurse. 3 care staff. (This is 1 extra to normal levels as 1 carer has been brought in to sit with someone who was very ill) 1 Nurse and 4 care staff. 1 Nurse and 4 care staff. Night Time 1 Nurse 1 Nurse and 2 care staff. 1 2 1 2 Nurse and care staff Nurse and carer staff. The acting manager and two clinical managers are supernumerary to staffing levels; they provide management cover for the home seven days a week. One person said to us in their opinion this had improved standards in the home. Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 21 There are also catering, house keeping and laundry staff employed at the home. At the time of the visit there were 52 people resident in the home. We felt the current staffing levels were sufficient to meet people’s care needs. However, should the home start to admit further people, staffing levels must increase to meet the needs of the increased number of people and sustain the improvements noticed during this visit. One relative commented in their survey that, “ Staff seem very caring and eager to help (generally)”. Another person said, “ New changes have been implemented with the increase of staff numbers (instead of agency staff) training skills have improved”. There is evidence that an extensive staff training programme is offered and has been implemented in the home. It is clear that improvements have been made. However not all staff are fully competent in caring for people with dementia. For example staff verbally offering people a lengthy list of options at breakfast, also staff failing to offer biscuits and provide side tables at mid morning coffee time. Continuous training and supervision is required to ensure improvements made are sustained. Numbers of staff with National Vocational Qualification (NVQ) are exceptionally low, with one member of staff having NVQ level 2 and two members of staff having NVQ level 3. However the acting manager reported that seven staff have commenced NVQ 2 training and a further eleven are waiting to sign up for the course. Staff, who spoke to us, spoke more confidently and positively about training and its availability. The recruitment records of three members of staff were checked during this visit. Recruitment records contained the necessary references and checks. We felt that some of the references obtained by a recruitment agency for overseas staff were difficult to verify. There were also employment gaps on applicants’ application forms and there was no evidence that these had been explained or investigated. Without verifying references and explaining any gaps in employment records, elderly vulnerable people may be exposed to unsuitable staff. Woodlands Nursing Home DS0000001100.V362053.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. EVIDENCE: There is no registered manager at Woodlands. However since September 2007 an acting manager has been in post. The acting manager, along with two clinical managers have improved standards at the home. They provide management and supervision cover for Woodlands seven days a week. People who returned surveys and spoke to us said that they felt more confident in the management team and felt they were approachable. One member of staff and two relatives who returned surveys said that communication in the home could be better. The management team should be aware of this and look at ways to improve this. A complex system of audits has been implement at the home. Woodlands management team looks at care plans on a weekly basis, to ensure they are written properly and identify all peoples care needs. Every day up to three Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 23 times a day a manager walks round the home and observes what is happening on each of the units. This gives the management team time to talk to people and staff, to observe staff working and observe standards of care in the Woodlands. Formal staff supervision sessions have also commenced. Overview audits of health and safety are completed monthly. Company audits are carried out monthly and each month the company decided which area or aspect of the home is to receive a full audit. Monthly relatives meetings have been taking place, however the Regional Director Mr Les Smith advised that at the last meeting relatives asked for the frequency to be reduced to every three months as the relatives as a group felt more confident in the standards of care and the investment made to improve the environment of the home. A check was made on three people’s financial records. Records and amounts of money held tallied and were found be correct. Records were clear and receipts were available. There are good records and evidence in the home that health and safety tests and checks are being done. However because someone in the home had been on sick leave the fire alarm system had not been checked one week. This system must be checked at least every seven days. Records of fire drills also showed that night staff have not taken part in regular fire drills. All staff must take part in at least two fire drills per year to make sure they know what to do in the event of a fire. Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 24 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 X X N/A X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 (1) (d) Requirement People must not be admitted to the home unless their needs can be met. Not assessed during this visit as no admissions to the home. All medication must be administered as prescribed and be available to administer from. This will make sure that people receive their medications correctly and the treatment of their medical condition is not affected. All people living in the home must have access to daily activities which meet their individual needs. There must be a robust recruitment procedure, which verifies references and seeks to record the reasons for gaps in employment histories. The fire alarm system must be checked at least every seven days. All staff including the night staff must take part in at least two fire drills per year to make sure they know what to do in the event of a fire. Timescale for action 15/08/08 2. OP9 13 (2) 15/05/08 3. OP12 16(2)(n) (m) 15/05/08 4. OP29 Schedule 2, regulations 7, 9, 19. 23(4) 15/05/08 5. OP38 15/05/08 Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Work should continue on updating care plans and training staff to ensure that care plans give clear and specific information about how people are to be cared for in Woodlands and record accurately what care has been delivered on a daily basis. The home should approach the local Primary Care Trust to help resolve the problem of local GP’s not wishing to take people from the home as permanent patients. The recording of the disposal of controlled drugs should include the quantity. This makes sure there is a complete record of these drugs entering and leaving the home. Care should be taken to ensure people have clean chairs to sit in, that their finger nails are clean and that the ladies in the home have their hair nicely styled by a hairdresser or staff. This should be done to help maintain people’s dignity. A light snack or biscuits should be offered with mid morning drinks. Drinks should not be offered until people have somewhere to safely place their hot cups of tea or coffee. Work should continue to ensure all staff are trained and understand safeguarding vulnerable adults procedures and practices. Chairs should be thoroughly cleaned to ensure they do not smell of stall urine. Training should continue with the aim being for the home to have 50 of its staff trained to NVQ level 2 or above. 2. 3. OP8 OP9 4. OP10 5. OP15 6. 7. 8. OP18 OP26 OP28 Woodlands Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Nursing Home DS0000001100.V362053.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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