Inspection on 05/07/06 for Woodstock Residential Home

This inspection was carried out on 5th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodstock Residential Home 28/06/07

Woodstock Residential Home 12/12/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Woodstock Residential Home 80 Woodstock Road Sittingbourne Kent ME10 4HN Lead Inspector Marion Weller Key Unannounced Inspection 5th July 2006 9:30 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 Woodstock Residential Home DS0000065797.V301936.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. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodstock Residential Home Address 80 Woodstock Road Sittingbourne Kent ME10 4HN 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) 01795 420202 Nellsar Limited Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: Woodstock Residential Home provides personal care and accommodation for up to sixty older people and is owned by Nellsar Limited. The home is located in a residential area on the outskirts of Sittingbourne, approximately two miles from the town centre and a main line railway station. The premises are large, with good car parking facilities to the front and a well-maintained, established garden to the rear. Residents’ accommodation is on two floors, accessed by either a passenger lift or a stair lift. There is a mixture of single and shared rooms. There is a good choice of communal areas available to residents both within the home and in the garden. The home employs care staff, working a roster, which gives 24-hour cover. Ancillary staff for catering, laundry, maintenance and domestic duties are also employed. Current fees range from £336.82 to £500.00 per week. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Marion Weller, Regulatory Inspector who was in Woodstock from 9.30 a.m. until 4.45 pm. During that time the inspector spoke with some residents, a visiting care manager assistant, the manager, the operations manager and some staff. Some judgements about the quality of life within the home were taken from observations and conversation. Some records were looked at. In addition, a tour of the home and parts of the garden were undertaken. The home currently has 35 residents and 25 vacancies. Nellsar Ltd were registered as the new provider of the home on 19th October 2005. The new manager appointed at that time is currently in the process of registration with the CSCI. Since the homes registration and appointment of the new manager much work has been undertaken. The home is therefore currently in a transitional stage, in the process of development and with firm plans for the future. This has been taken into consideration within the inspection process. Some comments from relatives and health professionals received shortly after the inspection indicated they were very satisfied with the standards of care. Statements made at that time included: • • • • “I’m extremely satisfied with the new Woodstock” “They look after people superbly” “They always put my mind at rest, I can leave the home feeling “everything is ok and my relative is well taken care of, -God bless them, that’s what I say” “The home offers so many activities and things for residents to do, its lovely” The manager and staff gave their full co-operation throughout the inspection. What the service does well: Woodstock Residential Home is welcoming and has a relaxed and inclusive atmosphere. Residents enjoy living in a spacious, clean and comfortable environment. Residents and their families benefit from a full assessment of their needs and being able to look around the home before they decide to move in. Residents are treated with respect. Arrangements are in place to maintain their privacy and dignity. Resident’s views are listened to and receive proper consideration. They are able to exercise choice and enjoy the extensive Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 6 range of leisure activities provided by the home. Resident’s general health and social care needs are well met by a competent manager and appropriately supervised staff. The home enjoys good relationships with other health care professionals. The home is sensitive about issues surrounding the ageing and death of a resident. Procedures are in place, which protect residents from abuse. Staff are kind and caring and the manager is approachable and understanding. Residents enjoy a wholesome and varied menu of meals. Resident’s visitors are made welcome. What has improved since the last inspection? What they could do better: The manager and the staff continue to work hard to update and improve procedures and systems within the home to meet current service demands and future development plans. Prospective residents and their representatives would benefit from clear and comprehensive written information about the home before they decide to move in which complies with regulation. Some residents would benefit from reassessment to ensure that the home can continue to meet their needs. Residents’ protection would be enhanced by improvements to the procedures for medication, infection control, safeguarding hot surfaces and water temperatures, the provision of specialist equipment and a review of staffing hours. A staff training matrix which gives a ready overview of staff training needs would assist with the homes commitment that all staff receive the training they need to safeguard the welfare of the resident group. Residents’ welfare would be further enhanced by improvements to quality assurance by the production of a self-monitoring system based on a systematic cycle of planning, action and review. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 7 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. Woodstock Residential Home DS0000065797.V301936.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 Woodstock Residential Home DS0000065797.V301936.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 123456 Quality in this outcome area is good. The judgement has been made using available evidence including a site visit to this service. People who use this service have most of the information about the home they need to make an informed decision about whether the service is right for them. The personalised needs assessment means that individual’s diverse needs are sensitively identified and planned before they move into the home which ensures residents are appropriately placed and the home can meet their needs. EVIDENCE: The home has a statement of purpose and a service user guide. The service user guide had been updated since the last inspection. The updated document contained a statement that the home was registered to provide EMI services. Although the home has made application for its current registration to be varied, this has not currently been agreed with CSCI. The manager stated that all such information documents would be removed from use immediately until the process of registration was complete. The previous statement of purpose and service user guide contained most of the information that prospective residents and their families would need, prior to making a decision to move in. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 10 Some minor amendments would provide residents with more detailed information and assure them that information was current. One comment from a residents relative illustrated that although they were satisfied that they had received sufficient verbal information about the home; they were not supplied with written information giving contact details for external bodies such as the CSCI, Health Care Authorities and local Social Service Departments. Terms and conditions of accommodation for residents had been reviewed since the registration of the new provider. All residents have a written contract with the home. Pre admission assessments are undertaken by the home. Documentation was seen which contained all the details required by regulation. Residents and relatives spoken with said that they and/or relatives could look around the home to see it was suitable before moving in. Both the operational manager and the manager demonstrated a clear understanding of the category and needs of residents that the home could meet. The manager continues to arrange for some residents to be reassessed to ensure that the home can continue to meet their long-term needs. Currently the home does not and has no plans to offer intermediate care. Woodstock Residential Home DS0000065797.V301936.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10.11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visits to this service. Although making significant improvements regarding the planning and delivery of care, some variable practices regarding medication administration procedures and poor record keeping potentially places service users at risk of harm. EVIDENCE: A plan of care is provided from a pre admission assessment for each resident. The document provides guidance for staff about actions to take to meet the health and welfare needs of residents. The manager and staff have reviewed care plan content since the last inspection. Documents seen were simplistic but effective. The staff groups understanding of residents individual needs was very good. Care plans seen included information regarding risks, healthcare appointments, medication and daily activities. Plans were reviewed regularly and changes documented. Residents and relatives were involved in reviews of care. The process was clearly evidenced in conversations held with relatives. Systems and procedures are in place for the storage and administration of medication in the home. Medication administration records (MAR) are completed appropriately, with no obvious gaps. Medication administration Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 12 records are kept with photographs of residents. A signature list for staff administering medication was in evidence. The list had been reviewed and updated as necessary. Drug storage is secure, including a lock on the medication fridge. Fridge temperatures are monitored regularly and documented on a weekly basis. Best practice suggests this should be undertaken more frequently to secure the safe storage of medicines. Documentation for temperature checks of the medication storage room could not be evidenced on the day of inspection, although the Team leader believed this to be undertaken regularly. Suitable facilities are available for the storage and administration of Controlled Drugs. Inspection of the homes controlled drugs register evidenced an inaccurate stock balance for a controlled drug. Two bottles of medicines were seen in the CD cupboard. The balance of one was correct and tallied with the CD register. The other, containing a full months supply of the same drug, had not been entered upon receipt at the home. Two fairly new medication trolleys were seen. Upon inspection one of the trolleys contained a large plastic container, labelled ‘spoilt medicines’. The container had a resealable lid and was at least ¾ full of unidentified tablets in various states of decay and spoilage. The Team leader stated it is the homes current practice to deposit and store any medication dispensed from the MDS system, but not taken or otherwise ‘spoilt’ by residents during medication rounds, into the container. On further inspection, the homes disposal/return to pharmacy records did not record the date of the individual spoilage event for the medicines stored, name and strength of the medicine spoilt, quantity removed, the name of the resident for whom the medicine was prescribed or purchased, or a signature of the member of staff who had witnessed and removed the ‘spoilt’ medication. A full medication audit trail for individuals, should it prove necessary, would therefore have been difficult to undertake. The necessity to obtain suitable advice from the homes dispensing pharmacist and the immediate review of both the homes current procedures and the records maintained for return and destruction of medication was discussed with the Team Leader and Manager. The manager stated that advice would be sought and practice and procedure in this area addressed immediately. The raised door threshold to the medication room was seen to make the removal and return of heavy medication trolleys difficult for staff. The Team Leader and manager stated that all staff whose task it is to administer medication was appropriately trained to do so. Records maintained by the home of regular checks of medication administrator’s competency could not be evidenced on the day of inspection. Records inspected and comments received indicated that the home has sound and productive working relationships with specialist and local health care professionals who support residents in their health care needs. Specialist nurses could be accessed if required and equipment for dealing with pressure sores can be obtained by the home as needed. Residents and their relatives Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 13 spoken with said that the quality of care provided in the home was good. From observation and discussion with resident’s relatives it was clear that staff treated residents with respect and promoted their privacy and dignity. Staff were seen to speak with residents in a respectful and appropriate manner. The manager demonstrated understanding regarding the ageing and death of residents. It was mentioned that the home aims to provide care for individuals as long as it is possible to do so. Relatives can visit and stay as often and for as long as they wish. Woodstock Residential Home DS0000065797.V301936.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this area is good. This judgement has been made using available evidence including a site visit to this service. An extensive range of activities in the home and those accessed in the community mean service users have a range of opportunities, which enable participation in stimulating and motivating activities. Meal and mealtimes are developing into an enjoyable social occasion for all service users. The manager has evidenced a good understanding of areas in which the home needs to develop further and actively seeks to involve service users in decision making. There is a good capacity for the service to further improve. EVIDENCE: The routines of daily living and numerous activities made available in the home aim to be flexible. In conversation with residents and staff it was clear that individuals could choose when to get up, when to retire and when to have a bath. Residents were seen to choose how they wished to spend their leisure time. The home has a dedicated activities coordinator for thirty hours a week. A diary record is kept of daily activities to inform and guide what is offered to residents. The coordinator has the capacity to offer both group and individual activities. A designated room is provided which contained a plentiful supply of Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 15 games, jigsaws, and art and craft materials. Activities provided recently included exercises, films, bingo and games such as giant snakes and ladders, which residents were enjoying on the day of the site visit. A number of social events had recently taken place; a B.B.Q and ‘a Gin & Tonic’ get together. A ‘Strawberries and Champagne party’ was planned for the coming week which was advertised on notice boards around the home. It was clear that resident’s friends and families were also very welcome to attend. Relatives spoke about previous events with pleasure. Staff confirmed that these events were very well attended and greatly enjoyed by all. The homes mini bus was said to be awaiting repair. The home has however offered trips out to small groups of residents to a local craft centre to look around and enjoy afternoon tea. Some individuals had been on shopping trips. Key workers were also said to look after resident’s recreational needs and also help individuals with any hobby or interest they may wish to pursue. Residents and relatives spoken with explained that visitors from local churches come into the home and individuals would be supported to attend religious services if they so wish. The home operates an open visiting policy which means relatives and friend can visit whenever they like. Residents are encouraged to keep in contact with their relatives and friends if they so wish. Relatives spoken to said they are always made most welcome. The design of the home provided ample seating in various areas, which were communal, or Residents could entertain their visitors in the privacy of their own room. Food was considered highly important and meal times seen as a social occasion. The cook was qualified and experienced in cooking for older people. The catering staff were well aware of the recorded dietary and cultural needs of each resident. They were committed to involving residents in menu planning and making sure they were able to enjoy the food they preferred and liked. The menu was varied, balanced and nutritious. The cook said the new owners gave a high priority to affording residents choice in their chosen diet, which was a great improvement for everyone. Staff gave assistance to those residents who needed help to eat in a discrete and sensitive manner. Mealtimes were relaxed; staff patient and helpful and residents were given the time they needed to finish their meal comfortably. Woodstock Residential Home DS0000065797.V301936.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 17 18 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. Service users feel listened to and their views are given proper consideration. However, the home must continue in its efforts to work in partnership with commissioning teams to secure more suitable provision for individual residents whose needs they are currently not registered to provide for. Every effort must be made to reassure and support all residents in the home during this sensitive process to secure their welfare, security and protection. The capacity the home currently evidences to improve this situation should result in better outcomes for people using the service. EVIDENCE: The service has a revised company complaints procedure. It is mentioned in the homes statement of purpose and detailed in the service user guide. It is easy to follow with appropriate timescales given for the homes response to a complainant. Residents were seen to be at ease talking with staff that listen to their views and concerns and give them proper consideration. The new manager was said to be very approachable by residents and relatives who were spoken with. The home had received two complaints since the last inspection. Both had been appropriately investigated, details recorded and the manager could evidence suitable outcomes. One relative mentioned they had not been given written contact details of other independent bodies that may help in matters of concern, but was sure that information could be accessed easily from the home. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 17 The manager said all permanent residents had been offered the opportunity to be registered for a vote. All of the homes policies and procedures have recently been reviewed following the registration of the new owners. There were procedures available for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. Staff spoken with had been recently trained and had a sound working knowledge of adult protection procedures. The manager said any allegation of abuse would be referred to concerned agencies without delay. The home is aware that a number of residents care needs are outside of the homes current registration category. This is a situation that the new owners have inherited and are purposefully trying to resolve with local commissioning teams. Because of the number of reassessments undertaken recently by care managers, several residents were understandably feeling very vulnerable. Staff do their best to reassure residents at every opportunity. This is a difficult, sensitive situation for all who are involved. The manager is aware that a swift resolution is required and that working with care managers to secure more appropriate provision for individuals is vital. Occupancy in the home is currently low. If the home were working at full capacity, there would be the potential for them not to cope as well with the situation as they evidently are. The home has made an application for a variation to their current registration to enable them to offer EMI services in a dedicated wing of the home. Refurbishments work in that area is progressing satisfactorily and has been undertaken to a good standard. The manager and staff stated that they are keen to provide continuity of care for some residents. It was made clear to the managers that their application for variation and the registration process is being dealt with outside of the inspection process. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 18 Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 19 Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.22.23.24.25.26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home continues to make significant improvements to the environment in line with their overall development plans for the home. Residents enjoy living in a clean, spacious and comfortable environment. They would be better protected by further improvements in the systems for infection control, safeguarding all hot surfaces and by the provision of identified specialist equipment. EVIDENCE: Refurbishment and redecoration of the home is ongoing. Work proceeds on a separate wing of the home where the owners intend to offer additional services. A member of staff is employed who is directly responsible for decorating, maintenance and the upkeep of the garden. The garden and patio at the rear of the property is very well maintained, with the garden arrangement creating separate areas with tables and seating provided. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 21 The home occupies large premises. Within the home several separate lounges are available offering residents a good choice of communal areas. There is also a residents smoking lounge, activities room, hairdressing salon and conservatory. Some new lounge furniture had been purchased and a large screen TV for residents use is available in one communal sitting area. There are currently thirty-one single bedrooms and 14 shared bedrooms. Some of which have ensuite facilities. All rooms have hand washbasins. There are 16 bathrooms available for resident’s use and adequate toilet facilities. Resident’s rooms were highly personalised and pleasant reflecting individual tastes and interests. It was said that all residents are provided with a lockable facility and a bedroom door lock. Some bedrooms were shared. The manager explained that some residents had made a positive choice to share a bedroom and careful consideration was always given to compatibility. Shared bedrooms were fitted with privacy screening to protect resident’s dignity. The new wing where additional EMI services are proposed to be sited, offers six shared rooms. Due to the mental frailty of these potential residents and possible associated behaviours, shared bedrooms should be reviewed, unless individuals are able to make a positive choice to share with the full understanding of the implications of the situation for their privacy and dignity, in that they would be sharing with people who were strangers to them. Accommodation for residents is over two floors accessed by either a passenger lift or stair lift. Not all rooms have level access and some raised door thresholds are present throughout the home. One resident’s room is at the top of a flight of stairs. There are ramps to the garden. A staff call system is provided. The inspector was assured that alarms were not necessary for external doors. The garden area was said to be secure. An occupational therapy assessment was carried out on the 12th December 2005. This was undertaken to assess the adaptations and equipment available at the home. The new owners commissioned the report to inform them and prioritise work required. The operations manager said that recommendations in the report would be acted upon. The Occupational Therapist made 12 recommendations. Work is still required to some areas mentioned. The manager evidenced a firm commitment to act upon the recommendations made. Some radiator guards have been installed throughout the home, some still require installation. Thermostatic mixer valves are fitted to resident’s baths and showers, but not to hand washbasins. Some hot water outlets tested on the day were very hot to the touch. Hot water temperatures are checked and recorded regularly. It was unclear if all hot water outlets were to be fitted with TMV’s to protect vulnerable service users. The general ventilation and temperatures of the home was appropriate on the day of the visit. Lighting is bright and domestic in nature. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 22 The premises are clean, pleasant and hygienic. The day of the inspection was very hot and humid. Some slight odour was present in some bedrooms. The manager said carpets in these areas are to be renewed under the refurbishment plans. Some new carpets and other flooring had already been replaced throughout the home. The laundry room was clean and contained suitable facilities, with the exception of a designated hand washing facility. Soiled and clean items are separated before laundering. The home has now improved the way they deal with soiled items by the introduction of a ‘red bag’ system, improving infection control procedures. The homes commode washer had broken down and was awaiting repair. Staff were washing commode pots by hand. Suitable personal protective equipment was in evidence for this task with the exception of facial and eye protection to avoid contamination from splashing with body fluids or cleaning chemicals. A safe procedure for washing commode pots by hand was not evidenced. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. The home can evidence significant improvement and the management team has robust plans to improve staffing and training programmes in the home. Residents would be better protected by the manager providing clear evidence of a recent staffing review and rotas that take into account good personnel practice, busy times and periods of high or low activity. Competency levels of designated medication administrators must be assessed to ensure they have the necessary skills to meet the needs of the residents and adhere to the homes procedures for the receipt, recording, storage, handling, administration and disposal of medicines. EVIDENCE: The home currently has 35 residents and 25 vacancies. At the time of inspection sufficient staff were available to meet the needs of residents. The home employs 22 care staff working a roster, which gives 24-hour cover and an activities coordinator. A further 9 ancillary staff are employed. Residents and their relatives spoke highly of staff saying they were friendly and helpful. Statements included: • “The staff and management have been extremely kind, helpful and sympathetic.” • “Staff are simply brilliant” • “Such kind, helpful and considerate staff” Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 24 In conversation staff were clear about their role and understood what was expected of them. There was a good understanding of the actions they need to take to meet and promote equality and diversity. The home has been successful with recruitment and substantive staff work additional hours to cover for rota absence. The manager said no agency staff are used in the home. A new staffing roster had been developed. The roster allocates twelve-hour working days to some staff. It is not immediately evident that this practice is in the best interests of residents or staff. The manager stated that some individuals prefer to work this way and rotas had been agreed with all staff before the roster was put into practice. Five staff are rostered in the mornings and again in the afternoon, with three waking night staff. The home however is geographically large and service is delivered over two floors, which can be very demanding of staff time. Catering staff prepares all the meals within the home, although care staff serve evening teas. Catering staff were concerned that there were busy times when an additional pair of hands were needed in the kitchen to meet the demands of cleaning schedules and other occasional, but necessary tasks. The operations manager said they were in the process of reviewing all staffing hours in line with the Department of Health Residential Formula. The home has robust recruitment procedures and on inspection these have been adhered to. All staff records and documents required by regulation were in order. Staff are required to undertake a comprehensive induction programme that includes all the elements they need to do their job well. The home has a commitment to raising standards by the expectation that staff will gain NVQ qualifications. At least 50 of staff (11) has NVQ qualifications. Some staff spoke of the support and assistance they were given in this. The new owners have developed a programme of appropriate training for staff. The home had individual staff training sheets but not a training matrix, which would give a ready overview of staff training needs. Such a tool would assist and support the robust commitment the home evidenced in ensuring all staff receive the training they need. The manager must assess and ensure the ongoing competency of staff that administers medication. They must have the necessary skills and knowledge of the homes procedures for the receipt, recording, storage, handling, administration and disposal of medicines to fully protect residents. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 36 37 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements are meeting the current needs of the service and the overall quality of the service is improving. EVIDENCE: The new manager was appointed at the time that Nellsar Limited was first registered as Provider on 19th October 2005 and is currently in the process of registration with the CSCI. Throughout the inspection, the manager clearly had the residents’ welfare at heart and demonstrated openness, commendable honesty and understanding of where shortfalls currently existed in best practice and the improvements to be made. Staff, residents and their relatives said they considered the manager to be very approachable, a ready listener and expected high standards. The home is welcoming and has a relaxed and inclusive atmosphere. Residents are able to approach staff with ease. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 26 There are clear lines of accountability within the home and with external management which residents and staff understand. The home is starting to regularly review aspects of its performance through review and consultation, which includes seeking the direct views of residents and relatives at residents meetings. Discussions and agreements made are recorded. Monthly audits are also undertaken by an external manager, which includes monitoring of any complaints, accidents and incidents. Results are documented. The new provider has a range of policies and procedures available for staff that had been reviewed to ensure they complied with recent legislation and good practice guidelines. The manager said staff had received training to make them aware of revised procedures and new documentation used in the home. Policy and procedure documents were available for staff to view in the duty office. Resident’s records and information maintained by the home are appropriately stored in lockable facilities. The manger stated that the previous owners had now returned most of the records pertaining to the home that were missing when they took over. The office is locked if unoccupied, which preserves residents confidentiality. Staff records seen complied with regulation. Staff supervision has been implemented and regular documented meetings are now set up with staff members. Residents’ interests were protected with families or their representatives dealing with their finances. The home currently holds no cash on behalf of residents. Neither residents nor their representatives expressed any concerns about the homes management of monies. The home was said by the operations manager to be financial viable and had access to professional business and financial advice and the company holds all the necessary insurance cover to enable it to fulfil any loss or legal liabilities. All new maintenance contracts have been set up since the homes registration. A fire risk assessment has been undertaken and recorded. The fire alarm system had been serviced. The fire logbook is completed appropriately and now includes checks of emergency lighting on a regular basis. Cleaning chemicals are stored securely. The manager also has plans to offer residents cabinets for more appropriate storage of toiletries. The manager stated that all windows are now fitted with window restrictors throughout the home. Arrangements are in place for the sound maintenance of food hygiene. The kitchen is clean. All dry food is stored appropriately. Records are kept for the regular testing of fridge, freezer and hot food temperatures. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 27 Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 28 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 ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 18 3 3 3 3 2 2 3 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1)(c) Sch 1 Requirement The registered person shall compile a statement of purpose in relation to the home, which shall consist of a statement as to the matters listed in Schedule 1. In that, the homes new statement of purpose needs further minor review and amendment to information given to comply fully with regulations. A statement must also be clearly made as to whether the home provides nursing or not. (Previous timescale of 28/02/06 not met.) The registered person shall produce a service users’ guide to the home. In that, the home must remove any reference to services provided in the recently revised document for which they are not currently registered. Further minor amendment to information given is needed to comply fully with regulation. Timescale for action 28/08/06 2. OP1 5(1) 28/08/06 Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 30 3. OP9 13(2) The registered person shall make 01/08/06 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the home. In that, Monitoring of the medication room and fridge temperatures must be undertaken and recorded more frequently. Improvements must be made to procedures for the receipt and administration of Controlled Drugs to ensure there is no mishandling. Pharmaceutical advice must be sought to aid the review and revision of the homes procedures for the disposal and return of medicines to the pharmacy. Staff that has delegated responsibility, as medication administrators must have their ongoing competency checked regularly and results recorded. Records should record actions taken to remedy any identified deficiency in required skills and knowledge. (An improvement plan detailing how the home will address these issues must be provided to the CSCI within the timescale given 4. OP22 23 (2) (n) The registered person shall 14/08/06 having regard to the number and needs of the service users ensure that suitable adaptations are made and such support, equipment and facilities as may be required are provided, for service users who are old, infirm or physically disabled. In that, The regional manger must Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 31 complete their stated intention of fully implementing the recommendations made by the Occupational Therapist following the assessment of equipment and the environment of the home undertaken on 12th December 2005. (An improvement plan detailing how the home will address the remaining recommendations made must be provided to the CSCI within the timescale given. The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; any activities in which service users participate are so far as reasonably practicable free from avoidable risks and unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. In that, hot water must be provided for residents at an appropriate temperature; hot water temperatures from all outlets must continue to be monitored and recorded on a regular basis and actions taken to remedy excessive temperatures recorded. All Radiators in service user areas must be low surface temperature or guarded. (An improvement plan detailing how the home will address these issues must be provided to the CSCI within the timescale given) 5. OP25 13(4)(a) (b)(c) 14/08/06 Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 32 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP4 Good Practice Recommendations It is strongly recommended that the regional manager complete their stated intention to continue with the reassessment of some residents where necessary to ensure that the home can continue to meet their needs. The use of shared rooms should be reconsidered with service users offered a single room or sole use of the shared room unless they have made a positive informed choice to share. With regard to the maintenance of infection control within the laundry room, it is strongly recommended that: Consideration should be given to a designated hand washing facility being installed. 4. OP26 With regard to the maintenance of infection control within the sluice, it is strongly recommended that facial and eye protection for staff is provided to avoid contamination with body fluids or cleaning chemicals when washing out commode pots by hand. A written procedure detailing the safe system of work to be adopted should be established and staff made aware. It is recommended that the regional manager complete their stated intention to review the staffing hours and rosters to ensure that residents needs can be met at all times. It is recommended that the regional manager complete their stated intention to review the staffing hours allocated specifically to catering activities to ensure the demands of cleaning schedules and other necessary tasks are met. It is strongly recommended that the regional manager complete their stated intention to develop a training matrix that provides a ready and clear overview of staff DS0000065797.V301936.R01.S.doc Version 5.2 Page 33 2. OP23 3. OP26 5. OP27 6. OP27 7. OP30 Woodstock Residential Home training needs. 8. OP33 It is strongly recommended that the regional manager further develop the quality assurance and monitoring systems based on a systematic cycle of planning-actionreview. Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 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 Woodstock Residential Home DS0000065797.V301936.R01.S.doc Version 5.2 Page 35 - 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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