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Inspection on 10/11/06 for Woodleigh Christian Care Home

Also see our care home review for Woodleigh Christian Care Home for more information

This inspection was carried out on 10th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A suitably qualified assessor performs effective pre-admittance assessments to ensure the holistic needs of the service users are identified. Service users at the home are treated with respect and dignity and their privacy is maintained effectively. Service users have the opportunity and choice to participate in varied and stimulating social activities. Service users are able to maintain contact with family, friends, and representatives from the local community as they wish and exercise choice and control over their lives. Service users are provided with a wholesome, appealing and balanced diet.Service users feel confident that concerns and complaints will be listened to and acted upon at the home and are protected from abuse. Service users benefit from a safe, well-maintained environment that is very pleasant, comfortable and clean throughout. An appropriate number and skill mix of staff are employed at the home to meet the service users needs. The recruitment process utilised at the home were effective in promoting the service user safety and appropriate training is provided to ensure staff are competent in meeting the needs of the service users. The home is run in the best interests of the service users. Service users financial interests are safeguarded and the heath and safety of service users at the home was promoted and protected.

What has improved since the last inspection?

The acting manager has initiated effective quality audit tools to ascertain the views and opinions of the service users at the home.

What the care home could do better:

Service users "holistic" needs identified within the service users care plans are not fully evaluated within the service users daily progress records. Service users are not fully protected by the homes policies and procedures in relation to medication management. The home does not have a registered manager in post.

CARE HOMES FOR OLDER PEOPLE Woodleigh Christian Care Home Norfolk Drive Mansfield Nottinghamshire NG19 7AG Lead Inspector Steve Keeling Key Unannounced Inspection 10 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 Woodleigh Christian Care Home DS0000039728.V316559.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. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodleigh Christian Care Home Address Norfolk Drive Mansfield Nottinghamshire NG19 7AG 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) 01623 420459 01623 460381 Mr John Richard Walton Dr Gail Margaret Walton Position Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (50), Terminally ill (2) of places Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Within the total number of beds, a maximum of 40 may be used for the category OP. Within the total number of beds, a maximum of 2 may be used for the category TI. Within the total number of beds, a maximum of 10 may be used for the category OP - over 55 years. 21st December 2005 Date of last inspection Brief Description of the Service: Woodleigh Christian Care Home is situated 100 yards from Chesterfield Road, which has a bus route into Mansfield town centre, approximately half a mile away. The property is an attractive two-storey, Victorian building, which has been extended in the last 10 years. It provides nursing and residential care for up to 40 older people in single and twin bedded rooms some of which have ensuite facilities. There is a shaft lift to assist independent access between floors. There are two lounges and two separate dining rooms. A well maintained enclosed garden provides a safe outdoor area and is accessible to all of the residents, there are also car-parking facilities on site. The home is run on Christian principles but accepts older people from other religions and cultures. The fees currently charged at the home range from £277.00 - £401.00 per week plus additional nursing rate when applicable. The fees charged at the home do not include services such as hairdressing, podiatry services and newspapers. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mr S.A. Keeling conducted the unannounced inspection on the 10th November 2006 over a 5.5-hour period. The main method of inspection was case tracking, this is a method of selecting service users within the home and discussing with them their expectations and experiences within the home together with the care practices utilised within the home environment. The case tracking method also examines the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the care home setting and that their safety and well being is being maintained. On this occasion two service users were case tracked. Also as part of the inspection process a staff member within the home was informally interviewed to further evidence the quality of care afforded to the service users. A range if information was used to determine the outcome of this inspection and the report, these included the previous judgments and findings, information received from service users in response to the Commission for Social Care Inspection questionnaires and the pre-inspection information provided by the registered provider in August 2006. The inspection also included a thematic inquiry as part of a national pilot scheme. This consisted of asking a number of standardised questions to a sample of the service users. The acting manager was informed and the agreement of service users was sought before asking a set of questions about the care they received. What the service does well: A suitably qualified assessor performs effective pre-admittance assessments to ensure the holistic needs of the service users are identified. Service users at the home are treated with respect and dignity and their privacy is maintained effectively. Service users have the opportunity and choice to participate in varied and stimulating social activities. Service users are able to maintain contact with family, friends, and representatives from the local community as they wish and exercise choice and control over their lives. Service users are provided with a wholesome, appealing and balanced diet. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 6 Service users feel confident that concerns and complaints will be listened to and acted upon at the home and are protected from abuse. Service users benefit from a safe, well-maintained environment that is very pleasant, comfortable and clean throughout. An appropriate number and skill mix of staff are employed at the home to meet the service users needs. The recruitment process utilised at the home were effective in promoting the service user safety and appropriate training is provided to ensure staff are competent in meeting the needs of the service users. The home is run in the best interests of the service users. Service users financial interests are safeguarded and the heath and safety of service users at the home was promoted and protected. What has improved since the last inspection? What they could do better: 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. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 7 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 Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 8 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): Quality in this outcome area is good. We looked at outcomes for the following standards 3, 6. This judgement has been made using available evidence including a visit to this service. A suitably qualified assessor performs effective pre-admittance assessments to ensure the holistic needs of the service users are identified. The home does not provide intermediate care services. EVIDENCE: The acting manager or her deputy manager performs effective pre-admittance assessments to identify the specific needs of the service users to maintain optimum independence and health within the home. The manager evidenced the documentation utilised within the pre-admittance assessments. The assessments were clear, concise and well presented. Once service users have undergone the pre-admittance assessment process the information is transferred to the homes computerised care planning system Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 9 and then qualified nursing staff at the home formulates care plans based on the initial needs assessments. The home does not provide an intermediate care service. The service users pre-inspection questionnaires asked “did you receive enough information about the home before you moved in so you could decide if it was the right place for you”, 100 of the responses received by the Commission for Social Care Inspection stated “yes”. In response to thematic enquiry questions-: Two case tracked service users were spoken with one the day of the inspection. One service user could remember that she had been given an up-to-date copy of the service user guide and stated that she was aware of the cost of care at the home and that the cost had not changed since she established residency in June 2006. She was aware that she had been given a contract of residency, which had not changed since she came to live in the home and could remember that the acting manger spoke to her about her care needs prior to their admission to the home. The second service user could not recall if the aforementioned information was provided on admission to the home. The second service users documentation was examined, it was evidenced that his family had received a copy of the service users guide and contract of residency on admission to the home in July 2006 as his family dealt with his financial affairs, a copy of the service users contract was evidenced on the homes computerised system. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is Adequate. We looked at outcomes for the following standards 7, 8, 9, 10. This judgement has been made using available evidence including a visit to this service. Service users “holistic” needs identified within the service users care plans were not fully evaluated within the service users daily progress records. Service users are not fully protected by the homes policies and procedures in relation to medication management. Service users at the home are treated with respect and dignity and their privacy is maintained effectively. EVIDENCE: A service user care plan in relation to urinary and faecal elimination stated that the service user should be frequency monitored in relation to urinary and faecal output. An examination of the service users daily progress records evidenced that this element of care had not been monitored effectively. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 11 A service users care plan in relation to weight monitoring specified that the service users weight should be monitored on a monthly basis. An examination of the computerised care plan evidenced that the last recorded weight was performed on 5th July 2006. An examination of the weight monitoring records for 29 service users who required weight monitoring evidenced that 21 service users weight was not recorded on the computerised care plans. A discussion with the acting manager evidenced that the service users weight was recorded on a weight monitoring sheet but the information had not been transferred to the computerised system. To ensure the safety of the service users the registered person shall ensure that elements within the service users care plans are effectively evaluated within the daily progress records. As far a practically possible service users or their representatives should be involved in the care planning process. It was evident that this requirement is not being addressed effectively at the home. Service users spoken with stated that they had not been involved in the care planning process. The acting manager stated that the computerised system utilised at the home has no facility to evidence the service users signature to demonstrate that informed consent has been given in relation to the content of the care plans. The registered person shall ensure that a system is initiated to demonstrate that informed consent has been obtained from the service user or their representatives when necessary in relation to content of the care plan. At the time of the inspection no service users were responsible for the selfadministration of medicines. The acting manager stated that should a service user wish to be independent in the administration of medicines a risk assessment would be performed, if the service user were deemed as being safe, the service user would be supported to be independent in relation to the self-administration of medication. As part of the case tracking process Medication Administration Records (MAR) were examined. Gaps within the MAR charts were evident with no explanation as to why the service user had not received the medication. MAR charts should not have gaps present, if medication cannot be administered an explanation must be documented and an appropriate “key” must be used. Hand written entries on the MAR charts did not evidence two signatures. All handwritten entries on MAR charts should evidence the person who wrote it and the person who checked the entry as correct so as to ensure the safety of service users at the home. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 12 To promote the safety of service users at the home, the acting manager had recently performed a quality audit relating to the standards of medication administration at the home to identify and rectify identified poor practice. In an attempt to improve medication management at the home the acting manager had audited the medication administration records between 16.10.06 and 05.11.06. The finding of the audit stated “whilst on the whole medicines administration is to a high standard their has been a significant number of occasions when this has not been the case”. The registered person is required to act on the findings of the medication audit to ensure the safety of service users at the home, repeat the medication auditing process to ascertain the effectiveness of medication administration at the home and ensure the safety of service users at the home. The temperature within the medication fridge had been monitored sporadically and was outside acceptable parameters on several occasions. To ensure that an optimum refrigerated environment is maintained to prevent medication degradation the temperature within the medication fridge should be within the range of 2 and 8 degrees centigrade. The registered person is required to ensure that medication, which requires refrigeration is stored effectively to ensure medication degradation is inhibited. The service users pre-inspection questionnaires asked, “do the carers listen and act on what you say”, 100 of the responses received by the Commission for Social Care Inspection stated, “yes”. Both case tracked service users were very complimentary in relation to all the staff at the home stating that their respect and dignity is maintained at all times. Comments received from service users on the day of the inspection included “No complaints whatsoever all the staff make a fuss off me, they are lovely”. “The staff are busy but wonderful. The home has a lovely feel, staff always respect my wishes and I feel safe. Personal care is always performed in private and my privacy is respected”. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at outcomes for the following standards 12, 13, 14, 15. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity and choice to participate in varied and stimulating social activities. Service users are able to maintain contact with family, friends, and representatives from the local community as they wish. Service users can exercise choice and control over their lives. Service users are provided with a wholesome, appealing and balanced diet. EVIDENCE: The service users pre-inspection questionnaires asked “are their activities arranged at the home which you can take part in”, 57 of the responses received by the Commission for Social Care Inspection stated “yes”, 15 stated “usually” and 28 stated “sometimes”. The acting manager stated that a Social Activities Coordinator (SAC) is employed at the home over 20 hours per week, mostly in the afternoons. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 14 It is the role of the SAC to ensure that service users can benefit from varied social activities within the home such as bingo, cards, dominoes and arts and crafts. Guest performers also visit the home to provide entertainment for the service users. Both case tracked service users stated that they particularly enjoyed the resent bonfire night display, which included a pie and pea supper. To promote interactions beyond the homes immediate environment, service users confirmed that they had recently accessed trips to the garden centre, a local park and other areas of local interest. A service user spoken with was looking forward to the homes annual Christmas fayre scheduled for 25th November 2006 and was busy making Christmas cards at the home. Through conversations with the case tracked service users and the staff at the home the inspector confirmed that the home operates an open door policy in relation to visitations. A service user stated, “Staff at the home are always welcoming offering tea and coffee to my visitors. Whilst another service users stated that “his family attended the bonfire night party which they really enjoyed”. To ensure that service uses can exercise choice and control over their lives the acting manager had recently formulated a “residents and relatives questionnaire”. The questionnaire examined satisfaction levels in relation to nursing care, dining experience, activity programme, admission process and facilities at the home. The results of the questionnaire were very positive and it is the intention of the acting manager to repeat the process to ensure the quality of care at the home remains at a high level. The acting manager also evidenced that a “professional user survey” had been recently formulated to ascertain the opinions of members of the Multidisciplinary Team (MDT) in relation to the quality of care at the home, the questionnaire will be distributed in the near future. The acting manager also stated that she intends to initiate service user meetings in the New Year to further establish the service users views in relation the service provision at the home. The service users pre-inspection questionnaires asked “do you like the meals at the home”, 71 of the responses received by the Commission for Social Care Inspection stated, “yes”, and 29 stated “usually”. Service users spoken with stated that they always have a choice of meals and that the homes chef always asked them what they would like to eat from the selection of meals available at the home. Service users spoken with stated that most meals are “traditional English” always hot and well presented and that meal times are relaxed and enjoyable. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 15 Both service users stated that they were happy with the quality of the dining room and stated that it is always clean and fresh. It is recommended that the registered person display a menu board in the dining room to promote the service users choice in relation to meal provision at the home. Currently a system is not in place to ensure that kitchen staff are aware of the service users at the home who require specialist diabetic diets. It is also recommended that a system is established which identifies service users who require a specialist diet in relation to diabetes management so as to aid the communication process at the home and promote the safety of the service users. Woodleigh Christian Care Home DS0000039728.V316559.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): Quality in this outcome area is good. We looked at outcomes for the following standards 16, 18. This judgement has been made using available evidence including a visit to this service. Service users feel confident that concerns and complaints will be listened to and acted upon at the home. Service users are protected from abuse. EVIDENCE: An examination of the staff training matrix evidenced that staff have received training in relation to the Protection of the Vulnerable Adult (POVA) although it was evident that some staff had last received the training in 2004. To ensure the service users are protected form abuse the registered person should ensure that all staff receive appropriate training updates in relation to POVA. The acting manager stated that all newly appointed staff are enrolled on the “Skills for Care” induction package and attend the local college, one morning a week whilst completing the induction package. An examination of the induction package evidenced that principles in relation to POVA are effectively addressed within the induction package thus promoting the safety of service users in the home. A staff member spoken with on the day of the inspection was able to demonstrate a clear understanding of issues relating to POVA. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 17 The member of staff stated that should she have any concerns in relation to POVA at the home she would ensure the safety of the service users, liaise with the senior member of staff at the home and consider contacting outside agencies such as Social Services, the Commission for Social Care Inspection or the Police if necessary. The service users pre-inspection questionnaires asked, “do you know who to speak to if you are not happy”, 100 of the responses received by the Commission for Social Care Inspection stated, “yes”. The acting manager was not investigating any complaints at the time of the inspection. An examination of the homes service user guide evidenced a complaints procedure is made available to all service users on admission to the home. The complaints procedure is also on display in the foyer of the home to aid the communication process. The complaints procedure gave specific guidance on how to make a complaint but did not evidence specific time scales in which the complaint will be addressed. The registered provider should ensure that the complaints procedure is amended within the service users guide to include specific times scales for addressing complaints and concerns. In response to thematic enquiry questions-: One service user stated that he could not recall being given a copy of the complaints procedure whilst a second service user stated that she had seen the complaints procedure within the homes statement of purpose. Both case tracked service users felt confident that should they have any concerns of complaints they could complain to any of the senior staff and were confident that their complaints would be dealt with appropriately. Both case tracked service users could not identify any concerns in relation to care provision at the home. The documentation of the service user who could not recall if the complaints procedure was provided on admission to the home was examined. It was evidenced that his family had received a copy of the service users guide, which contains the complaints procedure on admission to the home in July 2006. Woodleigh Christian Care Home DS0000039728.V316559.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): Quality in this outcome area is good. We looked at outcomes for the following standards 19, 26. This judgement has been made using available evidence including a visit to this service. Service users benefit from a safe, well-maintained environment The home provides a very pleasant, comfortable and clean environment for its service users. EVIDENCE: The service users pre-inspection questionnaires asked “is the home fresh and clean”, 42 of the responses received by the Commission for Social Care Inspection stated, “yes”, and 58 stated “usually”. The case tracked service users stated, “The home is always well maintained. All areas are clean and fresh as is my bedroom”, and “ the home is lovely, always clean and fresh, I am very satisfied with my room which is cleaned daily”. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 19 A partial tour of the premises was completed as part of this inspection process, which included the case tacked service users bedrooms and communal areas they frequent. The accommodation was well decorated, very comfortably furnished and maintained to a good standard throughout. The service users bedrooms were homely, safe and personalised with many personal possessions such as family pictures, small items of furniture, a television, radio and ornaments. To promote safety within the service users bedrooms window restrictors are in place and radiator guards, together with appropriately placed nurse call buttons to ensure staff can attend to service users needs effectively over the 24-hour period. The Kitchen and food preparation areas were examined on the day of the inspection. All areas were found to be very clean and well organised, food temperature is monitored effectively and food in the fridge was labelled and stored in the correct sequence. Woodleigh Christian Care Home DS0000039728.V316559.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): Quality in this outcome area is good. We looked at outcomes for the following standards 27, 28, 29, 30. This judgement has been made using available evidence including a visit to this service. An appropriate number and skill mix of staff are employed at the home to meets the service users needs. The recruitment process utilised at the home are effective in promoting the service users safety. Staff receive appropriate training and are competent in meeting the needs of the service users. EVIDENCE: The service users pre-inspection questionnaires asked “are staff available when you need them”, 42 of the responses received by the Commission for Social Care Inspection stated, “yes”, and 58 stated “usually”. Service users stated that although the staff are always busy they respond quickly when assistance is required. Thirty-one service users were accommodated at the home on the day of the inspection. The staff rota was examined and it was evident that one qualified nurse and five carers staffed the morning period; the afternoon period was staffed by one qualified nurse and 4 carers with the night period being staffed by one qualified nurse and two carers. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 21 Two Staff files were examined as part of the inspection process and it was evident that newly appointed members of staff only commence employment once satisfactory Protection of Vulnerable Adult (POVA) checks and Criminal Record Bureau (CRB) checks have been obtained, together with two satisfactory references. The manager evidenced that appropriate mandatory training opportunities are provided to care staff employed at the home. As mentioned earlier in the report all new staff are required to complete a comprehensive, theory based, induction process. The acting manager also evidenced that all staff are also required to complete a practical induction period at the home to ensure that all staff are proficient in the delivery of care at the home. The documentation appertaining to training provision was made available to the inspector from the homes computerised system. The documentation was very well managed by the homes administration officer and was clear, concise and easy to understand. The documentation utilised an effective colour coding system, which demonstrated training that was due, in progress, done or pending. The acting manager was able to evidence that staff at the home have attended training in relation to Moving and Handling, Infection Control, Health and safety, POVA training and Fire Awareness training. Woodleigh Christian Care Home DS0000039728.V316559.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): Quality in this outcome area is good. We looked at outcomes for the following standards 31, 33, 35, 38. This judgement has been made using available evidence including a visit to this service. The home does not have a registered manager in post but demonstrated competency in her acting managers role. The home is run in the best interests of the service users. Service users financial interests are safeguarded. The heath and safety of service users at the home was promoted and protected. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 23 EVIDENCE: The acting manager at the home has now been in post for approximately one year and as yet the Commission for Social Care Inspection has not received an application from the registered provider for the acting manager to be registered with the Commission. The acting manager stated that her application is now complete and will be forwarded to the Commission in the very near future so her application can be processed effectively and her suitability in performing the manager’s role at the home can be determined. The registered person should ensure that a manager is appointed at the earliest opportunity who has the required qualifications and experience to competently run the home and ensure the safety of service users at all times At the time of the inspection it was evidenced that the service users monies are managed effectively to ensure that service users are protected from financial abuse. A clear record of monitory transactions could be evidenced. Receipts for all monetary tractions such as podiatry service and hairdressing services were evidenced within the service users individual poly pockets. The administrator at the home, in the presence of another member of staff ensures service users financial record continues to be effectively managed, by performing quality audits on a two monthly basis in which all the service users financial records are checked. Service users spending money is stored securely and only the administrator and the acting manager have keys to the safe thus ensuring the service users are protected from financial abuse. In determining that the health and safety of service users is protected the inspector examined a range of Health and Safety information provided by the acting manager within the pre-inspection questionnaire. The documentation evidenced that the home is effectively maintained and provides a safe and pleasant environment of the service users. Woodleigh Christian Care Home DS0000039728.V316559.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 15 (1) Timescale for action The registered person shall, after 31/12/06 consultation with the service user, or a representative of his, prepare a written care plan as to how the service user’s needs in respect of his health and welfare and ensure elements within the care plan are effectively evaluated within the daily progress records. The registered person shall make 31/12/06 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. Requirement 2 OP9 13 (2) 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 OP15 OP16 Good Practice Recommendations The registered person should ensure that a menu board is on display within the dining room to aid the service users choice in relation to meal provision at the home. The registered should ensure that the complaints DS0000039728.V316559.R01.S.doc Version 5.2 Page 26 Woodleigh Christian Care Home 3 OP31 procedure is amended within the service users guide to include specific times scales for addressing complaints and concerns. The registered person should ensure that a registered manager is appointed at the earliest opportunity. Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Woodleigh Christian Care Home DS0000039728.V316559.R01.S.doc Version 5.2 Page 28 - 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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