Inspection on 19/12/06 for Woodley Grange

This inspection was carried out on 19th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Woodley Grange 18/09/07

Woodley Grange 21/11/05

Woodley Grange 10/06/05

Woodley Grange 21/12/04

Woodley Grange 13/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Woodley Grange Winchester Hill Romsey Hampshire SO51 7NU Lead Inspector Mr Rodney Martin Unannounced Inspection 19th December 2006 09:30 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 Woodley Grange DS0000011795.V324856.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. Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodley Grange Address Winchester Hill Romsey Hampshire SO51 7NU 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) 01794 523100 woodleygrange@lovingcare-matters.co.uk www.lovingcare-matters.co.uk Manucourt Limited Andrea Hardy Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36) of places Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 November 2005 Brief Description of the Service: Woodley Grange is a large detached property situated in a quiet residential area close to local amenities in Romsey, with close links to the M27 and M3. It is close to a local bus route into Romsey and Winchester and within easy reach of rail links to Southampton. Manucourt Limited owns the home. The registered manager is Andrea Hardy. The home is registered to provide personal care and accommodation for thirtysix older people who may, or may not have dementia. The homes website address for information is www.lovingcare-matters.co.uk. Accommodation is arranged on two levels. There is a shaft and stair lift giving access to the first floor accommodation. There are two large lounges, with dining areas. Both lounges open onto conservatories, which have delightful views over the homes pleasant and well-maintained grounds. There is ramped access to the front of the home and steps lead out to the rear of the property. The home has twenty single rooms and eight shared rooms. Although Woodley Grange is registered for thirty-six residents, one bedroom, which is under 10sq.m, is used, as a staff sleep-in room. Currently none of the bedrooms are provided with en suite facilities, however, the registered providers have plans to provide an additional twenty-bedded dementia unit, with additional facilities that are described in the environment section [Standards 19 to 26] of this report. The current fees are £400 to £475 per week. This information was confirmed on the day of the inspection. There are additional charges for hairdressing, newspapers and chiropody. The home provides residents with toiletries. Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place between 9.25am and 3.45pm. The process included an examination of documents and records, observation of staff practices, where this was possible without being intrusive and discussion with residents and a visitor. The inspector was also able to speak individually to staff. An opportunity was also taken to look around the home, including communal/shared areas, the home’s kitchen and laundry and a sample of bedrooms. The home’s registered manager was present throughout the visit and was available to provide assistance and information when required. On the day of the visit thirty-two residents were accommodated and of these eleven were male and twenty-one were female, whose ages ranged from 68 to 98 years. Included in the thirty-two, the home was accommodating two residents on a short stay. No resident was from a minority ethnic background. One resident has been in the home since 1983. There were two actions the home was required to do in the last inspection report, dated 21 November 2005, regarding the need to complete a written risk assessment to establish who is responsible for the administration of residents drugs and medicines and to introduce a quality monitoring system that seeks the views of residents. The home had complied within the timescale and there were no issues that required action following this inspection. The aims and objectives of Woodley Grange are “To promote and maintain a maximum level of independence and mobility. To provide a secure and caring environment for all our service users. To provide service users with a freedom to live their lives the way they choose, expecting only that they will respect all other service users in the home and the home’s own conditions of admission. To respect a service user’s individuality and privacy. To encourage service users to take pride in their appearance. To encourage service users to personalise their own rooms and keep them tidy. Service users will have the opportunity to make suggestions for improving the service the home provides. Visitors and guests are welcome at any time and may stay for meals by prior arrangement”. The home was found to be meeting its stated aims and objectives, on the day of the inspection. In line with the Commission’s policy, all the key standards were inspected on this occasion. Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: It was discussed having the menu displayed in picture form, to enable those residents with dementia make a more informed choice. The manager discussed devolving some of her management responsibilities to allow her more time on ‘the floor’ to spend some quality time with staff and residents. Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 7 One bedroom is affected by constant cleaning, due to the incontinence of the resident. A practical solution was discussed by replacing the carpet for a more appropriate floor covering. It was agreed that the manager would raise this with the resident’s family first. 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. Woodley Grange DS0000011795.V324856.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 Woodley Grange DS0000011795.V324856.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): 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives are given sufficient information to enable them to make an appropriate judgment about Woodley Grange. The admission process is well managed with an assessment completed, to ensure that Woodley Grange can meet the prospective service user’s needs. Woodley Grange does not provide intermediate care. EVIDENCE: On the day of the inspection Woodley Grange was accommodating thirty-two residents, which included two clients on a short respite stay. Although Woodley Grange is registered for thirty-six residents, one bedroom is used as a staff sleep-in room. The three vacancies were in a single room, a femaleWoodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 10 shared vacancy and a male-shared vacancy. The manager reported that six months ago the home had reduced to twenty-four residents, following the death of several residents in the home and some residents moving on to nursing care. However, the home has a good relationship with Romsey Adult Services as well as Social Services in Bournemouth and the vacancies were filled. The majority of residents have a diagnosis of dementia and there was evidence that the home is able to meet their needs. All residents are given a copy of the statement of purpose and service users guide, which also includes the complaints procedure, the home’s policy on having a locked door, charter of rights, the home’s aims and objectives and a copy of the terms and conditions of residency. A copy, which is kept in the resident’s room, was available on the tour of the building. The booklet is personalised with “welcome to Woodley Grange X [with the name of the resident inserted]”. A copy is also kept in the office to show visiting prospective residents/relatives. Referrals come from various sources, including hospital, Adult Services and private individuals. Following an initial inquiry, when basic details are obtained, if the manager feels they can meet the residents’ needs, the family are invited to come have a look around the home. The manager reported that she advises the prospective service user’s family to visit other homes for comparison as well as asking to see the last inspection report on the home. The prospective service user is then invited to come and spend the day in Woodley Grange, which would include having a complimentary lunch with the residents. This enables the staff to assess the individual’s capabilities as well as give the prospective service user an opportunity to see if the home is what they are looking for. The manager would visit the prospective service user in their own home or in hospital, if they did not come to the home for the assessment. A three-page comprehensive pre-admission assessment is completed, which includes sufficient information for the home to make an informed judgment regarding whether they could meet the perceived needs of the resident or not. Various residents were case tracked and their files seen, as well as speaking to them. Eighty per cent of residents have a diagnosis of dementia. There was evidence that the home is meeting residents’ needs. The inspector spoke to a visitor who said that there is “excellent care here”. Woodley Grange does not provide intermediate care, although prospective residents can come for a short respite stay, if there is a vacancy. Short stay residents are assessed in the same way as permanent residents. Woodley Grange DS0000011795.V324856.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, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ physical and emotional needs are met, as set out in individual care plans and risk assessments, with evidence of good multi-disciplinary working taking place on a regular basis. Residents are protected by appropriately trained staff, who follow the home’s policies and procedures for dealing with medicines. Personal support within the home is offered in such a way as to promote and protect residents’ privacy and dignity. The home has clear arrangements in place for supporting terminally ill residents in the way they prefer. EVIDENCE: Each resident has a separate ring-binder case file and is numbered according to the room number they occupy. The file is indexed for ease of access and Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 12 includes the resident’s personal details and photograph, medical information, the resident’s abilities for activities of daily living, various risk assessments, the monthly review of care, a health promotion record and a record of daily involvement. Various files were seen and residents spoken to. There was evidence that needs were met. For example one resident needs occasional oxygen. The cylinders are kept in their bedroom. A risk assessment is in place and staff have received training from the district nurses regarding the use of oxygen. The home is currently having problems with a resident’s behaviour, which may be relieved with a change in their medication regime. The manager reported that there is an issue regarding medication with this resident’s GP. However, the pattern of assistance required by this resident had been fully documented and a subsequent referral made to the psychogeriatrician, following the community psychiatric nurse’s visit to the resident. Care plans are reviewed monthly. The manager prefers that relatives are involved in the review process and that they come at least once every three months to attend the review. There was evidence of this. The personal and oral hygiene of each service user is maintained and recorded. All, bar two residents, are registered with the three surgeries in Romsey in Alma Road, Nightingale surgery and Abbey Mead. The two residents are registered with the surgery in North Baddesley. The manager reported that there is good support from the Romsey GP’s and community nurses. A community psychiatric nurse currently sees three residents. Medical examination is always done in the privacy of the resident’s room. Residents have access to all other health professionals on an as needs basis. A chiropodist comes every five or six weeks to the home, although one resident goes to Romsey Hospital for podiatry needs. Optical health care is when required, although an optician comes twice a year to the home. For dental care, residents can go to Romsey Hospital or see a visiting dentist. Some residents go out for medical appointments and one resident organises their own transport to see their GP. There was evidence from individual service users’ files of appointments with the dentist, optician, chiropodist and other health professionals. The home has a relevant medication policy, which satisfactorily details the receipt, recording, storage, handling, administration and disposal of medicines. The inspector saw medication being correctly administered with staff following the home’s medication policy and procedure. Although residents are able to self medicate within the home’s risk management framework, currently none are self-medicating. The home operates a monitored dosage system for administering medication. This is kept in a locked drugs trolley and in a locked cupboard. The home does not currently have any controlled drugs, apart from two residents who have been prescribed Temazepam. The drug administration sheets, which contained a photograph of the resident plus p.r.n details [as and when required] and any antibiotics, were satisfactorily recorded, with no Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 13 omissions. Generally only the care team managers dispense medication and other relevant staff have received medication training. All residents spoken with confirmed they are well-supported, treated with dignity and respect, and that they receive a high quality, consistent level of care. Staff members knocked on residents’ doors before entering and referred respectively to residents by their name, without patronising them. One visitor said that their loved one had settled well in the home and made friends and that they had no issues with the home and Woodley Grange provided excellent care. The home has a policy on death and dying and a procedure, for staff to follow, or what to do in the event of the death of a resident. Staff sign to say they have seen the home’s policies and procedures. The manager discreetly asks the prospective service user’s family their wishes regarding funeral arrangements et cetera, and this is recorded on the pre-admission assessment form. A resident’s family are also asked if they want to be contacted in the night, if the resident died as well as contact details about illnesses or accidents. Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ social, religious and recreational needs are met. Contact with family/friends/representatives and local community is encouraged as the individual wishes. Practices in the home demonstrate that the home promotes individual choices and encourages residents to have control over their lives. Dietary needs of residents are well catered for with a balance and varied selection of food available that meets residents taste and choices. EVIDENCE: The home endeavours to meet individual resident’s needs by ensuring the activity is geared to fulfilling their interest and taste. As previously noted, the majority of residents have a diagnosis of dementia and maintaining interest and concentration span is important in providing a fulfilling life, as the use of activities can significantly improve the quality of people’s lives. The home does have communal activities for residents to participate in, such as Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 15 reminiscence and exercises. Woodley Grange operates a keyworker system, where individual staff members can get to know a resident in more detail. Residents are able to go out shopping with their keyworker. There are visits to local hostelries, cream teas at the Hunters, external groups coming into the home, attendance at the local stroke club, Blind club and Red Cross. There is a church service three times a month. Manucourt Ltd, the registered providers, have another home and the manager there has a system of individual working with residents, called ‘mapping’. The manager at Woodley Grange reported that although they have a similar set up, she wants to develop ‘mapping’ more in the home; where from the time a resident gets up to the time they go to bed has a structure and meaning and where they can fulfil their full potential, incorporating activities of daily living as well as social/recreational activities. Contact with family and friends are maintained. Visitors can visit at any reasonable time and residents can see their visitors in the privacy of their bedroom or in the communal areas in the home. Some residents have few visitors and three residents do not have any visits from family, although the home is in telephone contact with relatives. On the day of the visit the inspector met a visitor and spent some time with them. They were very complimentary about the home, stating that they were made welcome and there was a very relaxed atmosphere in the home. Residents are encouraged by the staff to make choices in their daily life and these choices include choosing which clothes they will wear and what time they get up and go to bed. For example, on the day of the inspection one resident was still in bed after 10am. The home sent out a questionnaire to residents in February 2006 and one of the questions answered by several residents was that they would appreciate a lie-in, until 10am. This had been implemented with residents having breakfast in their room. Another request from the questionnaire survey was that some residents wanted a cooked breakfast. This also had been implemented with a cooked breakfast at present available once a week. Residents are also encouraged, where possible, to take control in their daily life. There was evidence that residents had brought their own personal possessions. The home is not appointee for any resident. Woodley Grange has two dining rooms. Residents, spoken to, said that the meals in the home were very good. The menu was on display and is written up each day by the chef. It was discussed having the menu displayed in picture form, to enable those residents with dementia make a more informed choice. On the day of the inspection residents had a choice of beef stew and dumplings or fish cakes, with mashed potato and fresh broccoli and carrots, followed by gateau and cream for dessert. The chef, works in the home fivedays a week and is suitably qualified, having obtained NVQ [national vocational qualification] level 1 and 2 in catering and interested in his role. On the day of the inspection a chef and kitchen assistant were on duty. Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy in place that is accessible to residents, their friends and relatives and members of staff. The home has an adult protection procedure, which protects and safeguards residents from abuse. EVIDENCE: Woodley Grange has a detailed and relevant complaints procedure, which is contained in the home’s statement of purpose and service users guide. Residents, spoken to, were aware of whom to complain should they have a need to and confirmed they had received a copy of the complaints procedure. The inspector spoke to a visitor who had no concerns about how the home is run or about the care their loved one receives. The home has a complaints log and only one complaint was recorded, since the last inspection. The Commission received correspondence from the complainant, regarding a short stay in the home. The manager had correctly responded and dealt with the issues raised. Although a meeting was offered to discuss the matter, the family did not pursue this option. The Commission was satisfied that the complaint was appropriately dealt with. The residents received a questionnaire in February 2006 and one of the questions related to the complaints procedure. It was noted, from the replies, that residents were aware of how to raise issues within the home. Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 17 The home has all the relevant documentation relating to adult protection, including a whistle blowing and the adult protection policy. Staff have received adult protection training. There was evidence from staff files that abuse training had taken place. There have been no incidents of abuse notified to the Commission. Woodley Grange DS0000011795.V324856.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, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A very good standard of accommodation is provided ensuring that residents live in a homely, safe and comfortable environment. Residents have individualised their bedrooms, to meet their needs. EVIDENCE: Woodley Grange has nineteen single bedrooms and eight double bedrooms, none provided with en suite toilet facilities. Although the home is currently registered for thirty-six residents, one bedroom, which is 9.3sqm and below the minimum standard of 10sqm, is used as a staff sleep-in room. The home has two-day rooms, with a conservatory off and two dining rooms. Since the last inspection 70 of bedrooms have had new curtains, carpets, furniture, new commodes and arm-chairs provided, as well replacing the dark Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 19 wood for lighter wood grain, to make rooms brighter. A new shower has been fitted in room 16 and a new bath provided in room 3. There is a commitment to improving the standards within the home by providing additional facilities for residents. The daughter of a resident wanted her mother to have a brighter light in her room, due to poor eyesight. The home provided a fluescent tube in the bedroom. The inspector was able to speak, by telephone, to one of the registered providers, on the day of the inspection. The home has planning permission to build an additional twentybed dementia unit, with bedrooms well above the minimum standard and an en suite toilet and shower. The registered providers want to move the kitchen and build a new one, as well as a new office, new laundry room, new hairdressing room, a staff training room and doctors/medical room. There are also plans to make the original front door the main entrance again and open up the area to create a more ‘homely’ feel. The laundry area is situated off the office area and is not adequate for the size of the home. However, as noted above, a new laundry room is due to be provided. The inspector was able to speak to the housekeeper. She has received COSHH [control of substances hazardous to health] training and the home has the necessary policies and procedures in place. Staff were observed to be complying with infection control procedures and practices. There was evidence of residents’ personal belongings in the rooms. There were no adverse smells noted, although one bedroom is affected by constant cleaning, due to the incontinence of the resident. A practical solution was discussed by replacing the carpet for a more appropriate floor covering. It was agreed that the manager would raise this with the resident’s family first. Woodley Grange DS0000011795.V324856.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good staffing levels and residents are supported by sufficiently trained staff, to ensure that their needs are met. Residents are protected by the home’s robust recruitment procedures. EVIDENCE: Woodley Grange employs nineteen care staff, including senior carers and four care team managers, with two ‘stand-in’ care team managers, plus ancillary staff members. Two staff members have worked in Woodley Grange over twenty years and over half the staff have worked in the home over six years. The home has a full complement of staff and does not need to employ agency staff. Care team managers work from 7am to 10pm and supervise care staff and monthly review the care plans. One care team manager does a sleep-in, three times a month and is also responsible for checking medication and residents’ money. The inspector was able to speak to staff. There was evidence that the staff team worked well together. A relative had written in a recent questionnaire, “The management and staff of Woodley Grange do an excellent job and I am very pleased the way X is looked after”. Eight of the staff team have obtained NVQ [national vocational qualification] in care at level 2 or 3 and a further three carers are currently on an NVQ course. All care team managers have obtained or about to obtain NVQ level 3. The Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 21 chef has obtained NVQ 1 and 2 in catering. Staff, spoken to, said that they received sufficient training and felt supported by management. Recruitment is by advertising locally in shop windows. The home also receives ‘cold’ canvassing by prospective staff. The manager makes a note of their name and details and either interviews straightaway or keeps it until there is a need for recruiting more carers. Woodley Grange endeavours to employ staff with the right attitude towards the care of the elderly with a preferred caring background. Consideration is also given to the applicant’s general manner, qualities such as integrity, honesty et cetera, love of working with older people and that they are prepared to do training. The applicant comes in for interview and completes the application form. The manager endeavours to interview three or more for a post. The prospective staff member pays for the PoVA first check [protection of vulnerable adults] and CRB [Criminal Records Bureau], which is refunded after six months in post. The manager reported that this has not been a deterrent but in fact confirms the applicant’s desire to work in Woodley Grange. Once the PoVA first check is returned the new carer is supernumerary for the first pone or two weeks, until the CRB is returned. Staff are taken on a six months trial. The files of new staff recruited were seen. The manager is to be commended on the quality of the staff files and the ease at which information was available in them. There was evidence that the home had followed the necessary checks before staff commenced their duties. As noted above, the majority of staff have worked in Woodley Grange for some time and consequently there is a balance of experience and skills within the staff team. Training is provided in-house as well as staff going on external courses. Two of the care team managers have done train the trainer in dementia. Staff attended a dementia care forum on 20 September 2006. Staff also receive training in the core training subjects of first aid, manual handling, food hygiene, health and safety, infection control, medication awareness, fire safety and protection of vulnerable adults; with the home having training videos in these subjects. The manager is in the process of producing a spreadsheet for all staff training, which will make for ease of reference. On the day of the inspection, thirteen staff members took part in a fire lecture and fire drill. Woodley Grange DS0000011795.V324856.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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is approachable and has an open style of management. She provides good leadership, which ensures staff are supported and residents’ health, safety and welfare promoted through the home’s practices. Staff are supervised as part of the normal management process within Woodley Grange. EVIDENCE: Andrea Hardy was appointed manager in August 2005 and is suitably qualified to run Woodley Grange having worked in various care settings. She has obtained the registered managers award for NVQ level 4 in both management and care. She communicates a clear sense of direction and leadership within the home and has been able to cascade relevant training to the staff. The Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 23 manager is supernumerary to the main duty rota. There is an open, friendly and transparent atmosphere within the home, which was also confirmed by a visitor and evidence obtained from questionnaires completed by relatives and residents in February and March 2006. Residents spoke warmly of staff and the way the home is run. Woodley Grange was awarded ‘Investors in people’ award in December 2005. The manager discussed devolving some of her management responsibilities to allow her more time on ‘the floor’ to spend some quality time with staff and residents. The home uses questionnaires to further ensure a quality control within Woodley Grange [these have been referred to in various parts of this report] and action is implemented where appropriate. A number of residents were spoken to and they were able to voice their opinions. There are regular monthly reports by the registered provider and the last one was on 20 November 2006. The manager is not appointee for any resident. Some residents’ pay directly for additional charges, such as chiropody and hairdressing and others are billed by the home on the monthly fee invoice. The home is currently holding money for twenty-two residents. Financial records were checked and were correct. A system of supervision is in place, which is split between the manager and care team managers. There is a commitment to staff training within Woodley Grange. Staff receive an appraisal of their work, once a year. Staff files were seen that indicated that there are regular supervision sessions. Staff, spoken to, were appreciative of the style of management in Woodley Grange and enjoyed working in the home. The fire logbook was inspected and the records indicated that the fire safety equipment had been tested and serviced within the guidelines. Staff received fire safety training in July 2006 and again, on the day of the inspection, which included a fire drill. The fire risk assessment was updated on 25 September 2006. The manager ensures the safe working practices by planning courses on health and safety within Woodley Grange, including first aid, adult protection, manual handling, food hygiene, fire and medication. A record is kept of accidents and incidents, including ‘slips, trips, falls’ and manual handling injuries. The manager types up the hand-written incidents and reviews them at the end of each month to see if there is any action the home needs to take. Risk assessments are in place. There are current and up to date contracts on electrical equipment as well as kitchen and domestic appliances et cetera. COSHH [control of substances hazardous to health] policies and procedures are in place. Window restrictors are in place on the windows above ground level, to ensure safety for residents. From a check of the records and practices observed in the home during the inspection, the health and safety measures taken in the home ensure the welfare and safety of the residents. Woodley Grange DS0000011795.V324856.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 3 X X 3 3 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Woodley Grange DS0000011795.V324856.R01.S.doc Version 5.2 Page 27 - 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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