Inspection on 06/11/07 for Woodleigh Christian Care Home

This inspection was carried out on 6th November 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodleigh Christian Care Home 14/08/09

Woodleigh Christian Care Home 10/11/06

Woodleigh Christian Care Home 21/12/05

Woodleigh Christian Care Home 05/08/05

Woodleigh Christian Care Home 08/03/05

Woodleigh Christian Care Home 11/08/04

Woodleigh Christian Care Home 12/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Woodleigh Christian Care Home Norfolk Drive Mansfield Nottinghamshire NG19 7AG Lead Inspector Steve Keeling Unannounced Inspection 6th November 2007 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.V348168.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.V348168.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 sam@woodleighcare.co.uk Mr John Richard Walton Dr Gail Margaret Walton Samantha Eves Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category:- Old age, not falling within any other category Code OP The maximum number of service users who can be accommodated is 40. 10th November 2006 2. 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 the majority of which have en-suite facilities. There is a shaft lift to assist independent access between floors. There are two lounges and two separate dining rooms. A well maintained 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 people from other religions and cultures. The fees currently charged at the home range from £290.00 - £500.00 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.V348168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. One inspector conducted the unannounced visit. The main method of inspection used was called ‘case tracking’ which involved selecting two residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. The manager, registered provider, members of staff and visitors to the home were spoken with as part of this visit. Documents were read as part of this visit and medication management was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken which included a sample of resident’s bedrooms, to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. A range of additional information was used to determine the outcome of this visit, which includes information received from residents in response to preinspection questionnaires and information provided by the registered provider within an Annual Quality Assurance Assessment (AQAA). As part of the inspection process, the registration certificate was reviewed with manager and the Centralised Registration Team at CSCI will follow up the issuing of new certificate which will include details relating to the registered manager. What the service does well: Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 6 Very comprehensive information in a variety of formats is made available to potential residents so they can determine that the service will meet their needs. A contract of residency is provided which clearly tells residents and their representatives about the service the will receive. Residents are involved in decisions about their lives, and play an active role in planning the care and support they receive. Principles of respect, dignity and privacy are put into practice. Residents are able to participate in a wide variety of recreational activities that meets the needs and expectations. Resident’s benefit from the provision of an appealing balanced diet are able to contribute the menu development. Staff have received appropriate training in relation to Safeguarding Adults and residents felt confident that any issues of concern would be addressed effectively by the manager. The physical design and layout of the home enables residents to live in a safe, well-maintained and very comfortable environment, which encourages independence and wellbeing. Staff in the home are trained, skilled and in sufficient numbers to support the residents and the recruitment procedure protects the wellbeing of the residents. The home is run in the best interests of the residents. The qualified, competent manager has developed effective quality assurance systems to promote the health and wellbeing of residents. What has improved since the last inspection? What they could do better: Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 7 Minor shortfalls were identified in relation to medication management, which were addressed on the day of the inspection. 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.V348168.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. We looked at standards 1, 3, and 6. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are supplied with comprehensive information they need to determine if the service will meet their needs. They have their needs fully assessed and a contract of residency. EVIDENCE: The resident’s pre inspection survey asked residents, “did you receive enough information about this home before you moved in, so you could decide if it was the right place for you?” 100 of the responses received by the CSCI stated, “yes”. Records showed that prospective residents are provided with a comprehensive service users guide that contains detailed information about the service. The guide is available in varying formats suitable to the needs of the people who Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 10 use service. Residents who already use the service have been involved in the process, giving their comments and experiences of living at the home. Residents who are unable to visit the home or have trial visits prior to gaining residency can utilise the homes wed site, care@woodleighcare.co.uk in addition a comprehensive picture book and a newly devised DVD is also available to provide detailed information relating to the service provision at the Home. Residents and visitors spoken with said they were fully involved in the admission process and recalled being supplied with comprehensive information relating to the service. Records showed that residents had undergone a full needs assessment before gaining residency and the assessment process was carried out by the manager who is a qualified Registered General Nurse (RGN). Additional information from Social Services Department is incorporated into the evaluation process when available. The pre admittance assessment documentation is stored in an electronic format and the computer network within the home is password protected to maintain the residents confidentiality. Records showed that the case tracked residents had received a contract which they had signed. The contract gives clear information about fees and extra charges at the home. Intermediate care services are not provided at Woodleigh Christian Care Home. Woodleigh Christian Care Home DS0000039728.V348168.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): Quality in this outcome area is good. We looked at standards This judgement has been made using available evidence including a visit to this service. Residents are involved in decisions about their lives, and play an active role in planning the care and support they receive. The health and personal care that residents receive is based on their individual needs. Shortfalls were identified in relation to medication management but actions were immediately taken to address the shortfalls. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The resident’s pre inspection survey asked residents “do you receive the care and support you need?” 80 of the responses received by the CSCI stated, “yes” with 20 stating “usually”. Records showed that care plans are developed to address the identified needs of the residents from pre admission assessments. In addition risk assessments are preformed to ensure any identified risks such as a residents susceptibility Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 12 to pressure sore formation, falls risks and concerns in relation to nutrition are identified and addressed through the care planning process. The care planning and risk assessment documentation is maintained in a computerised system with several computer stations throughout the home to aid the staffs’ access to information. Additionally the computer system prompts re-evaluations of the documentation on a monthly basis to ensure the changing needs of the residents are identified. One case tracked resident had been identified as at risk of Angina attacks on the pre-admittance assessment, although the resident had not experienced any episodes of angina since gaining residency, for approximately eleven months, it was recommended that a care plan should be developed to address the initial concern and the manager addressed the issue effectively. Records showed and a visitor confirmed that residents or their representatives are involved in the care planning process as residents or their representatives had signed “hard copies” of the care planning documentation. The resident’s pre inspection survey asked residents “do you receive the medical support you need?” 100 of the responses received by the CSCI stated, “always”. Residents spoken with confirmed that they are able to see their General Practitioner on request and records showed that residents had received additional interventions from community based specialist nurses, community pharmacists and podiatrists as required. Medication, which requires refrigeration, was stored within a secure fridge. The temperature within the medication fridge is recorded on a daily basis but the temperature was outside the require 2-8 degrees centigrade on several occasions in October 2007 and November 2007. To address the concern a replacement fridge was supplied immediately. Furthermore the documentation used for recording the daily temperatures was also amended immediately to specify the correct temperature, which medication should be maintained at, and the actions staff are to take should any concerns be identified in the future. A medication round was observed, the Medication Administration Records (MAR) were maintained effectively but a qualified nurse was observed to sign one entry on a MAR chart, on one occasion, before she had witnessed a resident taking their medication. The resident’s pre inspection survey asked residents “do staff listen and act on what you say?” 100 of the responses received by the CSCI stated, “yes”. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 13 A resident and a visitor spoken with said, “Staff very are caring and friendly,” and confirmed that residents respect and dignity is always promoted whilst performing personal interventions. Residents and visitors also confirmed that the routine in the home is very flexible in meeting the resident’s needs thus further promoting the residents respect and decisions as to how they spend their days. A visitor confirmed that the staff are welcoming and respectful at all times, and said that she had never witnessed anything that gives her cause for concern and said “this is a fantastic place”. Observations of staff and resident interactions were seen to be supportive, and relaxed thus affording the residents with dignity and choice, whilst offering encouragement and guidance. To further promote the residents respect and dignity records showed that residents and their representatives are regularly consulted on the service provision at the home, as regular residents meeting are performed. The outcome of the meetings is documented and the results of consultation process are made available to all residents and their representatives to ensure that good practice is maintained throughout the service. Woodleigh Christian Care Home DS0000039728.V348168.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): Quality in this outcome area is excellent. We looked at standards 12, 13, 14 and 15. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about their life style, and are supported to maintain individual choice. Recreational activities meet the needs and expectations of the residents and opportunities are available for residents to interact within the broader community. Resident’s benefit from the provision of an appealing balanced diet and are able to contribute the menu development. EVIDENCE: The resident’s pre inspection survey asked residents “ are activities arranged by the home that you can take part in?” 80 of the responses received by the CSCI stated, “yes” with 20 stating “usually”. Residents and visitors to the home confirmed that a full and stimulating variety of social activities are provided at the home and within the broader community. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 15 On the day of the inspection two trips were provided to areas of local interest together with a film matinee in the afternoon and an event entitled “what the local papers say” which is designed to keep residents informed in relation to current events in the media. The views of residents are sought when planning social activities. The “residents consultation notes” for September 2007 which 16 residents attended, stated that the residents particularly enjoyed the organised activities beyond the home environment which included a boat trip, trips out to do shopping, tea at a local Baptist Church and trips to local beauty spots and garden centres. In addition residents were very happy with the social activities provided at the home, which included a recent Bonfire Night party which was followed by a Pie and Pea supper together with coffee mornings and Christian services. The type and frequency of social activities is regularly reviewed by the two social activities coordinators employed at the home and records showed that amendments can be made at short notice to ensure the needs of the residents are met. The social activities programme is on display in the foyer of the home and showed that a comprehensive range of activities are provided. A Resident confirmed that her choice is respected in relation to participation in the social activities and was very satisfied with the activities provided. The manager stated that an open door policy is encouraged at the home and resident’s family and friends can visit as they wish. Residents and visitors to the home confirmed the open access stated that that the staff at the home always make visitors very welcome saying “they are excellent”. The resident’s pre inspection survey asked residents “ Do you like the meals at the home?” 60 of the responses received by the CSCI stated, “yes” with 40 stating “usually”. Residents said that they are consulted on and contribute to the menu provision at the home. A resident said “the food is lovely”. A Visitor to the home also stated, “The food is always good”. The variety of meal provision is enhanced as seasonal events such as harvest festival, summer fare, and Christmas and Easter are celebrated. The inspector observed that a good range of fresh fruit and vegetables was available in the kitchen area and the mid day meal on the day of the inspection Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 16 was well balanced and well presented. Residents also confirmed that they could have a drink whenever they wish and looked forward to meal times. The inspector observed that residents who require support during mealtimes were provided with soft meal options and assisted in a discrete, sensitive and unhurried manner thus ensuring that the residents could finish their meal comfortably and their respect maintained. Woodleigh Christian Care Home DS0000039728.V348168.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): Quality in this outcome area is good. We looked at standards 16 and 18. This judgement has been made using available evidence including a visit to this service. Residents are able to express their concerns and have access to an effective complaints procedure. Residents confirmed that they were confident that the manager would deal with concerns and complaints efficiently. Staff have received appropriate training in relation to Safeguarding Adults. EVIDENCE: The resident’s pre inspection survey asked residents “do you know how to make a complaint?” 100 of the responses received by the CSCI stated, “yes”. The survey also asked residents “do staff listen and act on what you say?” 100 of the responses received by the CSCI stated, “yes”. A complaints procedure is on display in the foyer of the home and residents or their representatives are given the complaints procedure within the Service Users Guide. Residents spoken with said they felt very safe in the home and that the staff are receptive to their needs and wishes at all times. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 18 A resident said she felt confident that she could report any concerns to the manager and said “the manager is available when needed to discuss any concerns I might have”. We asked a visitor to the home if she knows what to do if she was not happy with the service and would she be confident enough to make a complaint? The visitor said, “yes if I had any concerns I feel confident that they would be addressed straight away”. The manager was not investigating any complaints at the time of the visit and no complaints have been made to the manager at the home since the previous inspection. CSCI has received one complaint relating to the service provision at the home since the last unannounced visit, which was referred to Social Services Department. We contacted the investigating manager and it was confirmed that the complaint could not be substantiated. Training records showed that 95 of the care staff have received training in relation to the Safeguarding Adults and staff spoken with were able detail appropriate actions to be taken should they suspect abuse was happening. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. We looked at standards 19 and 26. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and very comfortable environment, which encourages independence and wellbeing. EVIDENCE: The resident’s pre inspection survey asked residents “ is the home fresh and clean?” 100 of the responses received by the CSCI stated, “yes”. A variety of communal space is avalable for residents use, which includes a number of different dining and lounge rooms together with quiet areas which residents can recive family and friends as they wish. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 20 A chapel areas is also utilised for the frequent religious services performed at the home. The homes internal environment, which included the dining rooms and the lounge areas, are very clean, warm, fresh, well lit and homely throughout. We observed that resident’s bedrooms are well maintained, clean and fresh and the fixtures and fittings are of a high quality and well maintained. Residents said that they are encouraged to personalise their bedrooms with their own furniture and personal possessions if they wish to further promote a homely environment. A nurse call system is fitted in every room. The home has a wider range of up to date specialist equipment and adaptations to meet the individual needs of the residents such as hoists and specialist bathing facilities to aid residents with impaired mobility, all were maintained effectively. All the residents spoken with were very satisfied with the standard of cleanliness in the home and confirmed that their bedrooms are cleaned on a daily basis, as are the communal areas. A visitor to the home said that the standard of cleanliness throughout the home was a significant factor in determining to suitability of the home in meeting the needs of her relative. A well-maintained garden area is available for residents use in the summer months. The garden area has recently been updated and landscaped to provide access to residents with impaired mobility via a ramp and the area has a range of garden furniture which includes a summer house for residents use. All areas on the first floor are accessible by two passenger lifts to aid residnets with impaired mobility. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. We looked at standards 27, 28, 29 and 30. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the residents who use the service. The home now has a robust recruitment procedure in place to protect the wellbeing of the residents. EVIDENCE: The resident’s pre inspection survey asked residents “ are staff available when you need them? 60 of the responses received by the CSCI stated “always” and 40 said usually. Staff employed at the home is sufficient to meet the needs of the 35 residents and an appropriate skill mix was evidenced. An examination of the staff rota, on the morning of the inspection showed five carers, and one qualified nurse were on duty throughout the day and 2 carers and one qualified nurse covered the night period. Additional staff are also employed at the busy breakfast period. The manager, administration staff and domiciliary staff are not included in the care hours. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 22 Residents spoken with said there always appears to be enough staff on duty and staff are always available when they need them. Staff files evidenced that a member of staff had commenced employment before satisfactory Protection of Vulnerable Adult (POVA) checks and Criminal Record Bureau (CRB) checks have been obtained due to an administration error. The required checks had been obtained approximately four months after employment had commenced and the discrepancy had been identified through quality auditing process performed by the manager at the home. Additional documentation relating to the recruitment process utilised at the home was in good order and well maintained. A staff-training matrix showed that the service has exceeded the required 50 of staff trained to NVQ National Vocational Qualification two and above as 95 of the care staff have or are working towards the qualification. A staff-training programme is provided in relation to Moving and Handling, Food Hygiene, Abuse Awareness, Health and Safety, Infection Control and First Aid. Records also showed that in addition to the aforementioned training care staff have received education in drug administration, supervision, dealing with difficult situations, project management, continence promotion, spiritual care, palliative care and customer service. Staff training records are very well maintained on the computerised system and were colour coded to aid the identification of training needs for the staff at the home. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. We looked at standards 31, 33, 35 and 38. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect to ensure the home is run in the best interests of the residents. The qualified, competent manager has developed effective quality assurance systems. Residents are protected from financial abuse and routine maintenance promotes the health and safety of residents. EVIDENCE: The manager is registered with CSCI and has almost completed her degree level, Registered Manager Award (RMA). Residents, staff and visitors to the home stated that the manager is very efficient, approachable and they felt Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 24 confident that that the service provission at the home meets the needs of the residents. The manager has responded well to the requirements and recommndations made from the previous inspection performed on the 10th Novemebr 2006 and it was clear that conciderable effort has been made to enhance the service. Minor shortfall identified on the day of the inspection were addressed immediately by the manager with the support of the registered provider. The manager demonstrated a clear vision of developments within the home. Staff said that the manager and the registered provider communicate a clear sense of direction at all times and felt that their opinions are listened to, and valued. Effective quality auditing systems are in place to determine the quality of the service and provides residents, staff and visiting professionals with the opportunity to contribute to the development of the home. In addition Care to Comment cards are also provided within the foyer of the home to provide an opportunity for visitors to the home to comment on the qualaty of care afforded to residents. Information gleaned from the comprenhencive quality auditing processes is corrilated by the manager and the results are openly avalable. Efficient systems are on place to ensure residents are protected from financial abuse. Following written consent from residents or their representatives, the manager will store small amonts of residnets “spending money” . Records showed that residnets money is individually stored within a secure area and all transactions are recorded and receipts are obtained. Comprehensive policies and procedures are available at all times and records showed that the policies and procedures are updated annually. All documentation was readily accessible and very well organised. A great deal of emphasis is placed on staff development. Records showed that following an effective induction process, which adheres to the “Skills for Care “ principles, staff are provided with regular training events to promote professional development and ensure staff can meet the needs of the residents. All records relating to staff training were very well organised, computerised and colour coded. Records showed that staff supervision and appraisals are performed to provide an opportunity to discuss staff performance and staff training needs. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 25 The registered provider is actively involved in the day to day running of the home and performs spot checks to ensure the quality of service provision is maintained to a high standard. Records showed that one accident had been recorded since the last inspection. Following the accident, effective risk assessments had been performed by the manager and the accident was viewed as an opportunity to learn and develop the service. As stated earlier in the report, the home is maintained to a very high standard throughout and information supplied by the registered provider within the AQAA evidenced that resident’s health and wellbeing is promoted by effective routine maintenance. Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 x 4 x 4 3 Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13 Requirement To promote the health and wellbeing of the resident’s staff must witness residents taking their medication before Medication Administration Records (MAR) are signed. Timescale for action 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodleigh Christian Care Home DS0000039728.V348168.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V348168.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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