Inspection on 21/08/07 for Woodthorne

This inspection was carried out on 21st August 2007.

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

Woodthorne 26/01/07

Woodthorne 16/12/05

Woodthorne 30/06/05

Woodthorne 19/01/05

Woodthorne 29/07/04

Woodthorne 26/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Woodthorne 12 Thompson Street Willenhall West Midlands WV13 1SY Lead Inspector Bhag Jassal Key Unannounced Inspection 21st August 2007 09:15 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 Woodthorne DS0000033323.V348787.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. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodthorne Address 12 Thompson Street Willenhall West Midlands WV13 1SY 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) 01902 606365 01902 606365 Miss Satwant Chahal Miss Satwant Chahal Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2007 Brief Description of the Service: Woodthorne care home is providing personal care and accommodation for 21 older people. The home is a Victorian detached property situated on the outskirts of Willenhall. It is close to local amenities. The home has been extended and now includes a single storey extension to the side of the existing property. The home provides eleven single rooms and five double rooms, providing 21 in all. There are wash hand basins in all the rooms. In addition to the lounge and dining area, there is a very pleasant conservatory, which overlooks an attractive patio and garden. There is ample car parking space. The present Responsible Individual/Registered Manager Ms Satwant Kaur Chahal has been operating this service since July 2002. Woodthorne care home makes their services known to prospective service users in the Statement of Purpose and Service Users’ Guide. The Inspection Report is mentioned in the statement of purpose and how a copy can be obtained. The care home rates are reviewed annually and service users are notified one month in advance. The only additional to people who use the service are for hairdressing and chiropody. This is clearly laid out in the terms and conditions. Fees for Woodthorne as at of 1st April 2007 are: £337.42 to £360. 76. All people using the service pay monthly. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is on a Key Inspection, part of which included an unannounced visit undertaken on 21st August 2007. This unannounced visit started at 09.15 am and lasted 8 hours and 55 minutes. The home had 19 places occupied and two remain vacant. The judgements made within this report are based upon information supplied by the home, from the interviews with staff, people who use the service and their relatives. During the course of inspection the assessment information and care plans were case tracked for 6 people who use the service. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken and observations of care practices and interaction between staff and people who use the service was also completed. Discussions took place with several members of staff and 12 people using the service and several visiting relatives were spoken to throughout the day of inspection. The Responsible Individual/Registered Manager – Ms Satwant Chahal was present throughout the inspection from 10.30 am. The Acting Manager Ms Rajwant Chahal was also present from 10.00 am onwards. All the information received from the care home was considered and discussed with both Satwant and Rajwant Chahal. What the service does well: The home makes every effort to provide individuals with a good care to meet the assessed needs following a care plan. The home has a good key worker and staff supervision system in place. The home communicates well with the families, friends and representatives of people using the service and welcomes visitors. People who use the service say they are happy and content with living in a homely and caring place. The home provides a relaxed, comfortable and friendly atmosphere where people are treated with respect and in dignified way. People using the service are often vulnerable both physical and emotionally and the Registered Manager/Owner – Ms Satwant Chahal ensures that staff are recruited with ability to carryout personal services for people sensitively and tactfully. The recruitment of good caring staff is critical to the running of care homes and Registered Manager/Owner at Woodthorne care home undertakes this carefully. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 6 The home now has a good training programme in place. A number of staff have received training in safe working practice topics, Dementia care, safe handling of medication and adult protection. Thus this training will ensure that they have improved their knowledge and skills to meet the changing needs of people who use the service. The home provides adequate standard of accommodation and facilities. What has improved since the last inspection? Four requirements out of six and two out of six recommendations made at the previous inspection had been addressed. The Registered Manager/Owner has gained the required qualifications and competent to manage the care home. Through conversation she demonstrated that she works continuously to improve services and provide an increased quality of life for people using the service. The Registered Manager is very service user focused, leads and supports an enhanced staff team providing them with improved training and supervision. This style and approach to management aims to pursue future improvements in all aspects of the service. The Registered Manager/Owner is now being assisted in achieving the above goal by the Acting Manager Ms Rajwant Chahal. The home has made good improvements in their record keeping and care planning. Care plans seen for people using the service were informative and give some indication of how care is to be delivered for each of them. Medication practices have improved and more staff have received training in safe handling of medication. The home now has over 70 care staff with NVQ Level 2 qualification. A number of staff have completed their training in Dementia care and that will enable them to expand their knowledge and skills and enhance the care they give to people using the service. It was noticeable that there have been some improvements made to the environment of the home. Three bedrooms have been provided with new carpets. Some of the fabric and furnishing in the home such as curtains in the lounge, dining and conservatory area and some individual bedrooms have been replaced. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodthorne DS0000033323.V348787.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 Woodthorne DS0000033323.V348787.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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodthorne provides detailed and clear information to people who will be using the service and their families to enable them to make decisions about whether or not to live at the home. Everyone receives full needs assessment prior to admission to the home to make sure that their needs can be met. EVIDENCE: Admissions are not made until a full assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. For people who are self-funding and without a care management assessment, they always receive assessment by the Registered Manager. Six files/care plans of people who use the service were inspected, which contained pre-admission assessments of their needs, both from assessments by the home’s senior staff and other relevant professionals. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 10 Observations and discussions with people using the service, their visiting relatives, the Registered Manager, Acting Manager and staff on duty indicated that the home continue to meet the needs of older people in a satisfactory and sensitive manner. It was noted from the staff training records that 10 members of staff have received training in Dementia care. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Everyone who uses the service has an individual plan of care, which ensures that their personal, healthcare and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People who use the service are treated with respect and dignity, and their right to privacy is understood and upheld. EVIDENCE: People using the service undergo an assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a good key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Six care plans of people using the service were case tracked and examined in detail. There was evidence to show that the short-term goals and long-term goals, aims and objectives were clearly identified and appropriate interventions required to put into action to meet the individual needs of people using the service were also clearly identified. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 12 The Registered Manager stated that a new care plan format was implemented prior to the previous inspection of 29 January 2007. The staff reported that this new system seems to be working well. The formats are computerised and a care plan summary can easily be updated and printed off. Risk assessments are also completed and were comprehensive including nutrition, falls, pressure sores and mobility. Key workers produce a personal profile from history provided by the people using the service, their relatives and visiting professionals. People using the service and/or their relatives are encouraged to read and sign the care plan if they are happy with it. Discussions with people who use the service showed that the home has a strong ethos of involving them in all aspects of their life. The care plans that were read were clearly written and included an element of risk assessment. Information from the initial assessments had been written into the plan of care. The care plans are reviewed on a monthly basis by senior staff. However, it was it was seen that there were some gaps in recent reviews of care plans. The daily care recording formats were also examined and it was noted that the quality and detail of care recording needs further improvements. The Acting Manager stated that all care plans will be reviewed and updated as a matter of priority by mid-September 2007. The Acting Manager also stated that she will ensure the staff are ensure the staff are made aware of the importance of including all the information regarding people using the service and their well-being, and all the entries made by the staff are always to be cross-referenced to their care plans. Furthermore the staff will be closely supervised and supported to make further improvements in daily care recordings as a matter of good practice. The home maintains records of all health checks carried out by the GPs, dentists, opticians, chiropodists and district nurses. It was evident from the care plans seen that the home ensures that the detailed nutritional screening is undertaken, including a weight gain and loss records are maintained and appropriate action is taken if required. It was observed on the day of inspection that no personal care interventions were undertaken in communal areas. In addition, consultation with health and social care professionals are carried out within the bedrooms of people using the service. Visitors are able to meet people using the service in their bedrooms, in the lounges and conservatory on the ground floor, which offers privacy when not being used. It was observed that people using the service were being treated with respect and staff are working both professionally and sensitively in meeting individual needs. The Inspector spoke at some length with ten people using the service and all of them commented positively about the their care and they felt that they have everything that they need. Eight people using the service stated that “the Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 13 carers are very good and kind and they look after us very well”. Two other people using the service said “the carers are always there to help”. The people using the service were very happy with the upgraded garden and patio areas at the rear of the premises. Several relatives visiting the people who use the service also commented positively about the tranquil garden and safer patio areas. Generally people using the service appeared to be content, comfortable and happy. Hey were complimentary regarding the quality of their lives and the care they were receiving at Woodthorne care home. Discussions with the Registered Manager, Acting Manager, and the staff training records showed that several carers have completed their training in safe handling of medication. However, it is the home’s policy that the senior members of staff would be responsible for the safe handling and administration of medication. Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines have been given. Records seen included medication received, administered and leaving the home. It was also seen that the mobile medication trolley was securely and safely stored after use near the Manager’s office. The photographs of people using the service have been provided on medication sheets to avoid any risks of maladministration of medication. The former treatment room is now being used as a general store room. Woodthorne DS0000033323.V348787.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. The home provides a good programme of social and leisure activities and outings, which are designed to meet the needs, choices, preferences and capabilities of people using the service. Visitors are welcomed and there are links with the local community. People who use the service are positively helped to exercise and control over their lives as far as practicable and safe to do so. The dietary needs of people who use the service are well catered for with a balanced and varied selection of foods, of ample quantities to meet the tastes and individual requirements of people using the service. EVIDENCE: The home provides an activities programme in accordance with everyone using the service, their choices, preferences and capacities in relation to – social, leisure and cultural interests. People using the service, who were able to give opinion, were complimentary about the activities provided, and particularly the external entertainers. People using the service are enabled to enjoy a full and stimulating life style with a variety of options to choice from. A record of Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 15 activities participated is kept and photographs of major events displayed in the home. People using the service were seen sitting in the lounges and conservatory chatting to staff and visitors. Several people using the service stated that they preferred to sometimes sit quietly in their bedrooms and the staff respected this. On the day of inspection, the people using the service were engaged in the hairdressing activity and chatting to each other. Several people using the service spoken to stated that they were in regular contact with their family members and friends, and spoke about their visitors’ involvement and interest in their care matters. The visitors’ book kept in the home showed a considerable activity. The people who use the service also contacts with the local community – for example, church services, pubs, shops and park. The staff was preparing for a trip for people using the service to Weston Super-Mare on 23 August 2007. The Acting Manager stated that the people using the service were positively encouraged and helped to exercise their choices, and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. The Acting Manager also stated that a close liaison is maintained with the relatives and representatives, where the people using the service are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of the Advocacy Service based in the local area. The information about the Advocacy Service is included in the home’s Statement of Purpose and Service Users’ Guide. Several people using the service told the Inspector “the home is very good and its peace and quite here”. “The food was very nice well cooked and tasty”. The consensus of people using the service was the range, quality and choice of food provided was very good and the home catered for those people using the service, who have individual preferences and medical needs. The Acting Manager stated that the menu is changed on a regular basis in consultation with the people using the service. The kitchen is well equipped and kept clean and tidy, which meets the requirements of the local Council’s Environmental Health Department. The vacant posts of catering staff are being filed shortly, but in the mean time cooking duties are being covered by the designated care staff. Woodthorne DS0000033323.V348787.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 adequate. This judgement has been made using available evidence including a visit to this service. There is a clear Complaints Procedure in place, a copy of which is made available to people who use the service and their relatives. This should ensure that any complaint made is listened to and acted upon. The home has an Adult Protection policy and procedure but formal training is required for all staff to ensure that people who use the service are appropriately protected from abuse. EVIDENCE: The home has a good Complaints Procedure in place, which is referred to in the home’s Service Users; Guide and in the Statement of Purpose. There is a system of recording concerns and complaints. The home has also introduced a Whistle Blowing Policy and a comments/suggestions box located in the reception area allowing for anonymous replies. The Commission for Social Care Inspection (CSCI) has not received any complaints about the care home since the last inspection of 29th January 2007. Nor have there been any adult protection issues. The staff training records showed that several members of staff have received training in adult protection issues. The Registered Manager and Acting Manager stated that the other members of staff who as yet have not undertaken this mode of training will do so shortly. This training will assist staff to obtain knowledge and understanding of the signs and symptoms of Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 17 abuse and reduce the risks of abuse to people using the service. the Acting Manager stated that the staff are expected to report any concerns to their line manager and action would be taken in line with the home’s own policy and procedure and also in line with Walsall’s Adult Protection Procedures. Woodthorne DS0000033323.V348787.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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained but needs some improvements to décor, fittings and safety matters. The home generally clean and hygienic. EVIDENCE: The home offers a comfortable and generally well-maintained environment to people who use the service. The home has ample communal space – a large lounge and dining areas and a conservatory. The home has a rolling programme of redecoration to maintain good standards. The garden and patio areas were well - maintained. The home has replaced carpets in three bedrooms on the ground floor. An assessment of the premises and facilities has been carried out by an Occupational Therapist on 21st May 2007. Some of the recommendations contained in the OT’s report are still to be implemented. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 19 However, the tour of the premises highlighted a number of issues that must be addressed to the internal environment. The decoration/paint work is looking tired in some areas and in need of refreshing. The Acting Manager stated that there is a planned programme for maintenance with timescales for specific jobs, including redecoration of bedrooms and communal areas, and renewal of old furniture, fittings and carpets. The hot water supply in several bedrooms was not sufficiently working and needs to be rectified promptly in order to ensure the people using the service enjoy a regular supply of hot water without the risk of scalding or not having the supply sufficiently of hot water. The Acting Manager and the Registered Manager stated that the post of Handy Person has been vacant since July 2007 and that has not helped the home with various outstanding maintenance jobs, including redecoration work. The following deficiencies must be addressed to ensure the safe and comfortable living environment for people using the service: Replace carpets in the stairs, bedrooms and lounge area. Provide a bath hoist and replace floor covering in the first floor bathroom, refurbishment of the shower room/toilet leading from the lounge, replace fused light bulbs in several bedrooms and lounge/dining areas, reseal surround of sinks in several bedrooms and provide suitable window restrictor in bedroom 6a on the first floor for the safety of the service user. The home was found to be generally clean, tidy and free from any unpleasant odour. The home has good policies and procedures regarding infection control. It was noted from the staff training records that majority of staff have not yet received training in infection control and COSHH. The Acting Manager stated that this mode of training will be provided as a matter of priority. The vacant post of a laundry assistant/cleaner is still to be filled. This continued vacant post could have adverse effect on the state of cleanliness and laundry service for people using the service. The requirements and recommendations contained in the recent inspection reports of the Fire Safety Officer and Environmental Health Officer are still outstanding to be fully implemented. Woodthorne DS0000033323.V348787.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 adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty throughout the day needs to be revised and improved sufficiently to meet the needs of people using the service. The recruitment procedures have improved to fully protect people using the service. The home continues to support staff to complete training, but not all staff are yet adequately trained to do their jobs. EVIDENCE: Information provided by the home and the available staff rotas on the day of inspection indicated that the home is not adequately staffed at all times to meet the particular and specific needs of people using the service. It was noted from the staff rotas for the month of August 2007 that there is one senior carer and a carer on duty during the day, a trainee carer on some shifts. There are two night carers on wakeful duty. The Acting Manager stated that there are vacant posts of cook 22 hours per week, laundry/domestic assistant 10 hours per week and handy person 15 hours per week. In addition, there is no cook cover for the evening teatimes throughout the week. The care staff are expected to cover laundry and cleaning duties at the weekends. The carers are also expected to cover duties in the kitchen in the evening teatimes throughout the week, which means Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 21 effectively that there is insufficient care staff on duty to provide care and supervise presently 19 people using the service. The issues related with the above insufficient staffing levels were discussed with both the Registered Provider/Manager and the Acting Manager. They are to take appropriate action to provide adequate levels of care and ancillary staff on duty at all times, including in the evenings and at weekends. They undertook to ensure that there will be one senior carer and two carers on duty throughout the day and supported by cook, laundry assistant, cleaner and maintenance person at all times. Staff were spoken to and all stated that despite the changes in staff recently they felt they were for the better and now they were beginning to work as a team. There is good balance within the staff team, which includes experienced, mature and younger staff, who are embarking on a new career. The relatives spoken with also made observations about the staff team “they all are working hard in the present circumstances to provide good care and attention to our relatives living here”. People who use the service were full of praise for care staff stating ”they are caring and kind and do everything for us”. It was noted from the staff training records and discussions with staff and the Acting Manager that 12 members of staff have completed their NVQ Level 2 qualification and two carers are currently undertaking their NVQ Level 2 training. The Acting Manager stated that the remaining staff will undergo this mode of training shortly. It was noted that a number of staff have undertaken their mandatory training in safe working practice topics. It was noted that not all members of staff received training in safe working practice topics and they all will be put forward to undertake this mode of training shortly. For example, Fire Safety training for all staff will be delivered in September 2007. Staff will also be nominated to receive training in adult protection, Dementia care and safe handling of medication shortly. All new staff to receive their induction training in accordance with Skills for Care standards/requirements, and staff confirmed that they are supported by the home for any training needs that they have. Since the last Key Inspection, the home has operated an acceptable recruitment procedure. On inspecting 6 staff files, it was noted that now all staff are POVA and CRB checked. Two written references are also obtained. There was evidence on files that staff receives statement of terms and conditions of employment. There is now staff training and development programme in place, which is being implemented. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is trained and experienced to lead a team of staff. The ethos of the home is based on openness and respect. People who use the service can be assured that the home is generally run in their interests. Financial interests of people who use the service are safeguarded. The home generally promotes the health, safety and welfare of people using the service, but needs some further improvements. EVIDENCE: The Registered Manager – Ms Satwant Chahal has completed her required qualifications to meet the standards. She has achieved her NVQ Level 4 and RMA qualifications. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 23 Observations made and discussions with people using the service, their relatives and staff indicated that the Registered Manager is very approachable and she operates an “open door” policy. People using the service who could express themselves stated that they are happy to approach the Manager and senior staff with any problems they might have and were confident that they would respond to them appropriately. Through discussions with the Registered Manager, she demonstrated that she is confident in her ability to lead a staff team whilst being fully aware of the individual needs of people using the service. The Acting Manager also showed her commitment to improve the quality of care for people using the service and staff training and development. Equality and diversity for people using the service were seen to be promoted throughout the home within the assessments, care plans, and activities. Equality for staff is promoted through the opportunities for training at all levels. All members of staff have an annual staff appraisal of their training and development needs. The home has also implemented the formal staff supervision system to ensure that all staff receives their 6 formal supervision meetings. Quality Assurance takes place throughout the service in both a formal and informal manner. Meetings, surveys, internal audits/checks, day to day contact, all provide records to show that the satisfaction of people who use the service is at the heart of the service. However, the questionnaires to people using the service, and their relatives have been sent out in mid –August 2007 to obtain their feedback on the quality of services and facilities provided by Woodthorne care home. The Acting Manager stated that she will analyse and prepare a report on the outcome of the feedback by the end of September 2007, and the report will be made available in the home and a copy to the CSCI. The Home also needs to obtain feedback from other stakeholders and visitors to the home and analyse their response as well. In addition, the Registered Manager should consider developing systems for determining the views of people using the service with Dementia/mental health needs/problems, who are unable to verbalise their needs. Financial records and administrative procedures relating to the handling of monies of three people using the service were inspected and were found to be well ordered and maintained. The home has good health and safety policy and procedures, and staff were aware of their responsibilities regarding these issues and a number of staff have received training in these issues. Matters pertaining to fire safety and environmental health need to be maintained to the required standards and all the outstanding issues identified in the recent inspection reports of the Fire Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 24 Safety Officer and the Environmental Health Officer should be addressed appropriately and promptly. All safety systems and equipment are regularly checked and well - maintained and records of all tests/checks are kept up to date. However, the Emergency Lighting System needs to be tested on a monthly basis and all tests records kept and Fire Drills also needs to be carried out at the required intervals and all members of staff to receive Fire Safety training. The staff training records indicated that there were many gaps in mandatory training for staff that includes Fire Safety, First – Aid, health and safety, basic food hygiene, COSHH, and infection control. The Registered Provider and the Acting Manager are aware of this deficiency and they both are taking appropriate steps to rectify this unsatisfactory situation shortly. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X X X X X 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 X 2 X 3 X X 2 Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 26 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 OP20 Regulation 16(1&2c) Requirement The Registered Provider must replace worn and or stained carpets in bedrooms and communal areas to ensure a comfortable environment for people using the service. (Previous timescale of31/03/07 not met). Timescale for action 31/10/07 2. OP38 18 31/10/07 Staff must receive training in respect of:First – Aid Health and Safety Fire Safety Infection Control/COSHH Food Hygiene Fully qualified staff in First Aid on each shift in order to ensure that health and safety of people using the service. 3. OP18 13 (6) All staff must receive adult 31/10/07 protection training to ensure that people using the service are not at risk of harm and abuse. All new staff must receive their DS0000033323.V348787.R01.S.doc 4. OP30 12 & 18 31/10/07 Page 27 Woodthorne Version 5.2 Induction Training in accordance with the Skills for Care standards and requirements to ensure the safety and protection of people using the service. 5. OP33 24 The Registered Provider must 31/10/07 provide an effective quality assurance and quality monitoring system to measure success in meeting the aims, objectives and Statement of Purpose of the Home. (Previous timescale of 31/05/07 not met) The Registered Provider must obtain feedback from stakeholders and visitors to the home on the quality of services and facilities provided to people using the service, as a part of the Home’s Quality Assurance monitoring system. 6. OP27 18 15/10/07 The Registered Provider must ensure that all the vacant posts of carers and ancillary staff (cook, laundry assistant, cleaner and handy person) are filled as a matter of priority, and adequate care and ancillary staffing levels must be maintained at all times in order to ensure the care needs of people using the service are appropriately met. Action must be taken to ensure that the hot water supply in the bathrooms and several bedrooms is assessed and appropriate mechanisms are put in place in order to minimise the risks of scalding of people using the service. The Registered Provider must DS0000033323.V348787.R01.S.doc 7. OP38 23 (2)(j) 15/10/07 8. OP19 23 (4 & 5) 31/10/07 Page 28 Woodthorne Version 5.2 take appropriate action to implement all of the outstanding requirements and recommendations contained in the inspection reports dated 16 August 2007 and 26 April 2007 respectively of the Fire Safety Officer and the Environmental Health Officer in order to ensure safe, secure and comfortable environment for people using the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended for good practice that a six monthly review is offered and held for all privately funded service users with their relatives and for others where the statutory review has not taken place. It is recommended that the service users’ care plans should be reviewed at least once a month to ensure that any changes of need are identified and addressed. It is recommended that the details and quality of daily care recording should be further improved. The Registered Provider should refurbish the bathrooms and shower rooms. Review and develop the range of activities available to people using the service with mental health/dementia care needs and those with sensory impairments. The Registered Provider should provide an assisted bath on the first floor suitable to meet the assessed needs of people using the service. DS0000033323.V348787.R01.S.doc Version 5.2 Page 29 2. 3. OP21 OP12 4. OP22 Woodthorne It is recommended that all of the outstanding recommendations contained in the Occupational Therapist’s report dated 21May 2007 are implemented appropriately. 5. OP19 It is recommended that the system should be put in place to ensure that the essential repairs such as those identified in this report are dealt with promptly. Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Woodthorne DS0000033323.V348787.R01.S.doc Version 5.2 Page 31 - 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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