Inspection on 26/01/07 for Woodthorne

This inspection was carried out on 26th January 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 21/08/07

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 Chris Fuller Key Unannounced Inspection 10:00 29TH January 2007 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.V319262.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.V319262.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.V319262.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2005 Brief Description of the Service: Woodthorne is a Victorian detached property situated on the outskirts of Willenhall. It is close to local amenities. Woodthorne is a registered care home for 20 older people. 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 fees at the home range between £327.27 and £349.92. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This year the Commission for Social Care Inspection is making a proportional key inspection against a selected number of the National Minimum Standards. The focus remains on assessing the quality of care provided through the experience and outcomes for service users, a review progress on meeting National Minimum Standards from the previous inspection and focusing on aspects of service provision that require further development, or pose the most significant risk to service users. Some standards have not been inspected on this occasion. The unannounced inspection of Woodthorne residential home was made on Monday 29th January 2007. The registered manager provided the pre inspection information and was available to assist with the process of the inspection. The Inspector spoke with care staff and residents. Records and residents files were seen. A tour was made of the communal areas of the premises and some of the individual rooms. Feedback was received from eleven residents, eight relatives and friends and one placing social worker. The majority of comments were very positive and satisfied with the standard of care provided in the home. Where suggestions were made these have been included in the report. One of the residents said, “The staff are excellent I couldn’t wish for better attention. I think it would be difficult to find another home where everyone is so well cared for.” • • • • • Further progress had been made with some of the outstanding statutory requirements. External and refurbishment work had been done during the spring/summer of 2006. The feedback from residents was positive about both the personal care and the food provided at the home. The home has a relaxed and friendly atmosphere with conversation and good humour between staff and residents. Maintenance and repairs are routinely reported and recorded by staff and completed in a timely manner. What the service does well: The premises offer a Victorian building with traditional features of stained glass, high ceilings, providing spacious and homely accommodation. From the lounge and conservatory and some bedrooms there is an outlook of a pleasant rear garden to view or sit in and enjoy. The home does have a number of shared rooms to offer to married couples and or those that prefer to share and enjoy the companionship of others. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 6 The staff team work well as a team and have developed good relationships with the residents and their relatives. This encourages a social and community atmosphere in the home that is warm and welcoming. Residents are encouraged to maintain their individual lifestyle preferences through choices of individual daily routines and a range of social activities and events. What has improved since the last inspection? What they could do better: Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 7 A longstanding statutory requirement is for the premises to be assessed by an occupational therapist; this is important for the health and safety of the residents, given their physical needs and the nature of the premises. Bathrooms and shower rooms should also be considered for refurbishment. These are part of an ongoing programme of repairs and development of the property to achieve the national minimum standards. The home must prioritise development of a quality assurance system in the home through resident and family feedback questionnaires, monitoring of the systems and the statement of purpose by the management team. The registered manager must establish a programme of regular supervision sessions to monitor care practice and provide support to staff. 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.V319262.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.V319262.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 and 6 Quality in this outcome area is good. Progress has been made with clear policy and procedures for initial assessment and admissions being implemented by the management team. This ensures the prospective resident is kept informed and the home is able to meet the needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management are in the process of revising the statement of purpose and the welcome pack for residents. A copy of this is provided for each resident in their room. Information is provided to prospective residents and their relatives such as a brochure or welcome pack prior to admission to give information about the home. This information along with visits to the home enable potential residents and their relatives to make informed decisions. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 10 Contracts have been updated to provide all relevant information including the individual Room number and are signed and dated by all parties. These had been issued to all residents with a copy held on file. A sample of residents files were seen and found to be generally in good order with a front index for easy reference. The relevant assessment of needs records were found to be completed and held on file. The home has an admissions policy and procedure last reviewed in August 2006. Following referral or enquiry to the home the registered manager makes a visit to the prospective resident to complete the home’s assessment of need. The manager will also request a social care or nursing care assessment and care plan. The resident and or their relatives will be consulted for information and to inform them of what the home can offer. Woodthorne DS0000033323.V319262.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. The care plans and health plans are comprehensive and an effective key worker system ensure that the health, personal and social care needs of each resident are met. Staff are trained in the safe administration of medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new care plan format was implemented at the last inspection visit. Staff report that this 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 resident, relatives and visiting professionals. Residents and or their relatives are encouraged to read and sign the care plan if they are happy with it. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 12 A review of the care plan is completed monthly by care staff and any changes or amendments updated. Some of the residents have statutory reviews arranged by the placing social worker however this does not happen regularly and does not occur for privately contracted arrangements. The value of involving residents and relatives in regular reviews was discussed and it was recommended for good practice that a six monthly review is offered and held for all private service users with their relatives and for others where the statutory review has not taken place. The health care of residents is included in the care plan. The home is registered for older persons however in the pre inspection information the registered manager states that five of the residents have dementia care needs and five have mental health care needs. The registered manager is aware that only appropriate admissions can be made. The home is not registered to accept residents with Dementia Care needs. Whilst it is helpful that the staff have completed training in dementia care the home is not set up with facilities or services to meet the needs of residents with Dementia. The home does seek appropriate support from the medical and health services for residents with specific health care needs. One of the residents is Diabetic and stated “I’m an insulin dependent diabetic and the staff understand my needs especially if I have a hypo or other problems.” Another resident commented that “The doctor takes too long to come out and see me.” Staff explained that with some surgeries this can be a problem and the key worker will pursue an appointment or home visit if there are health concerns. Generally staff are pro active in making health care appointments such as optician’s, dental and chiropody and record any treatment or follow up visits and action to be taken. The administration of medication was observed on this inspection. The pr inspection information names four staff with accredited training that are responsible for the safe handling and administration of medication. The medication cabinet is stored in a hallway while in use and then locked in a storage cupboard when not in use. The home is contracted with Boots the Pharmacist and this is a new arrangement with support provided by the Pharmacist. Administration of medication records were well ordered, clear labels and current, complete records. There is a record book for controlled drugs and homely remedies. The management and staff at the home promote the privacy and dignity of residents in all aspects of their care practice. There are some aspects of the premises such as shared rooms and use of the shower room that require the discreet use of screen’s or curtains to ensure privacy is attained. Similarly with Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 13 personal care or assistance to residents staff are discreet and considerate of individual needs such as sitting to assist at meal times etc. Woodthorne DS0000033323.V319262.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. The management and staff group aim to develop a social atmosphere and life in the home through promotion of communal activities and personal interests or hobbies. Relatives are made welcome and are invited to join in with events in the home or outings in the local community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home strives to promote a social life for residents and visitors to the home through encouraging residents to maintain the relationships they have in the local community and making family and friends welcome in the home as well as enabling residents to maintain their independence and go out into the community. All main calendar events are celebrated such as Christmas, Easter, Halloween, Bonfire night etc. Staff at the home have made progress in developing a programme of activities for the residents including board games, dominoes, knitting and gardening. There are other sessions such as hand and nail beauty treatment, treat your Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 15 feet session, a walk in the garden or paint and drawing session that residents enjoy. There is a Sunday morning worship event that some residents like to attend and some group sessions involve discussion of past events and current news. A couple of the residents attend local day centre clubs. A few times a year the home will arrange trips out and meals out and family are welcome to join in if spaces are available. The Registered manager stated that following completion of training in dementia care the opportunities for stimulation through activities has been developed and particular consideration has been given to people with dementia, and those with visual and hearing impairments. One of the residents keeps a pet budgerigar. The home also has tropical fish. However feedback from residents gave varied response in respect of activities one resident said “I can only take place in some activities due to my poor eyesight and hearing.” Another stated, “I would like more activities that I could take part in as I have no mobility and am also very deaf.” Further work needs to be done to ensure all resident’s needs are being met. Residents are encouraged to bring some of their personal items into the home at the time of their admission. The individual rooms visited had been personalised with pictures, photos, ornaments and some items of furniture and reflect the personality and character of the resident. There are examples on file of residents being consulted and encouraged to keep responsibility and control of their own possessions, money, medicines etc. Risk assessments are completed to enable residents and manage any potential hazard or concerns. Residents may access their personal records and residents and or their families are involved in writing of care plans and sign and date their agreement wherever possible. The inspector was at the home over the lunch time period and took lunch with the residents and also spoke with the cook. The general feedback on the comment cards and when speaking to residents was that they were very happy with the food provided and they knew the cook and felt they were asked about their food preferences and likes and dislikes. The cook does keep a record of discussions with the residents and their food preferences and mealtime choices. Breakfast time the residents have a choice of hot or cold breakfasts. On the day of the inspection the cook provided a vegetarian dish and residents had stewed beef or salmon with mashed potatoes, peas and carrots. The dining room is colour co-ordinated with the through lounge and has attractive laid tables with flower centres and tablecloths and mats. One of the residents recently celebrated her 100th birthday and cook always makes a cake and buffet to celebrate. In the summer time a barbecue is held in the garden on fine days. One of the residents stated “The staff are exceptionally thoughtful about my food as I need to be careful about my diet. A selection of fruit is always available.” Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The home has policy and procedures for Complaints and the Protection of Vulnerable Adults. Staff are experienced and trained in respect of Adult Protection issues and safeguard the welfare and well being of the residents in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has policy and procedures for receiving and investigating Complaints. All policies were reviewed in August 2006. A copy of the complaints procedure has been sent out to relatives during the past year. The resident’ guide / welcome pack is currently being revised and a summary of the complaints procedure is included. The registered manager reports that there have been no complaints received during the past inspection year. The staff are encouraged to address issues as they arise and to bring any concerns to the attention of their line manager so that these can be resolved to protect the welfare and well being of the residents. Relatives are encouraged to talk to staff and management should they have any concerns and key workers and senior staff inform relatives of any changes in the residents care plans or wellbeing. The home has received several Thank you cards and letters for the care provided to residents and these are displayed on the notice board for a short period upon receipt. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 17 The policy and procedures for the Protection of Vulnerable Adults are held in the main office and readily available to staff. Staff complete training in Adult Protection Awareness and most have covered modules in the NVQ training. Staff have a knowledge and understanding of the signs and symptoms of abuse. Staff are expected to report any concerns to their line manager and action would be taken in line with Walsall Adult Protection Procedure. There have been no incidents reported during the past inspection year. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24 and 26 Quality in this outcome area is adequate. The provider has a commitment to improving the premises and facilities at the home. There continues to be a gradual upgrading of the facilities with a few matters outstanding. It is important these are addressed to provide a safe and comfortable environment for residents and so that progress made in other areas is reflected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The judgement reflects there are outstanding statutory requirements however the premises are generally well maintained and there is evidence of a continuous programme of improvement since the provider purchased the home. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 19 The premises consist of a large Victorian house with many of its original features with stained glass windows, high ceilings, sash windows and spacious rooms providing a pleasant living areas. There are plans to extend the building using the existing shower room for the staff office and six to eight new rooms with en suite facilities. These proposals explain some of the delay in outstanding requirements and recommendations such as bathrooms and carpets as these would be planned in with the development of the premises. The provider shows a commitment to developing the property and there have been improvements made to the premises with a new wall with ironwork fencing and gates at the front of the house, external decoration and some planting to make the home look attractive and well maintained. The rear garden is maturing and provides a pleasant area for residents to look out on and to sit in during fine weather. Internally decoration in ongoing in communal and individual rooms. The lounge is colour co-ordinated with new curtains and the dining area is laid up attractively at mealtimes. The kitchen was seen and found to be well organised and clean and tidy with new equipment provided such as microwave, kettle, storage shelves, flooring and fly screen. Some of the individual rooms seen had new armchairs and curtains. In one shared room (Room 1) new chairs were sited in front of wardrobes and so staff and or residents would constantly have to move these to get into the wardrobe. This was discussed at the time of the visit and it was agreed the arrangements for furniture in the room would be reviewed and risk assessed. Generally before a new resident moves in a room will be refreshed with decoration and furnishings as needed. There is a maintenance person and the cook also does additional hours to assist with maintenance, decoration and gardening duties. A record is kept of maintenance and repairs to be done and when the task is completed. The Fire Officer was consulted regarding the Fire Exit arrangements in the main lounge and the French doors are now used as the Fire Exit. These are kept clear at all times. There is a programme for deep cleanse of carpets and this has improved the general appearance in the home. However several areas are becoming worn and torn and the provider confirmed there are plans to replace hallway and staircase carpets. The premises have not yet had an Assessment of the premises and facilities is by a qualified Occupational Therapist. This has been discussed with the registered manager on several inspection visits and advice given how to obtain a list of local occupational therapists. Due to the age and structure of the premises and the resident’s needs it is appropriate that a professional be Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 20 consulted regarding any aids and adaptations or improvements to the premises that may be required. The Registered Person / manager has provided a new bath hoist in the downstairs bathroom and a new floor hoist. It would benefit residents if a bath hoist was provided on the first floor suitable to meet the assessed needs of service users. All of the bathrooms and shower rooms are maintained clean and hygienic however they are in need of refurbishment. The seal on the bathroom floor is torn and needs to be repaired as this may present a trip hazard. A new call bell system is being provided throughout the home to update systems and ensure all residents are able to request assistance as they need it. The emergency call system was last checked in September 2006. The laundry room was seen and found to be well organised, clean and tidy. Equipment was in working order and the provider / manager agreed to replace the worn ironing board cover. All care staff take responsibility for the laundry sharing tasks between shifts. Residents confirmed they were satisfied with their laundry and generally there was no problem with items being returned to them. One of the residents said, “It is very well run, it is clean, beds are clean, the food is good and I always have help if I need it.” Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. The systems for staff recruitment, staff files and training are in place for providing a sufficient number of competent and qualified staff. Management promote staff development and training and all have done well to exceed the minimum number of NVQ qualified Staff. Staff appraisals must be completed to annually review and maintain the development staff and provision of good standards of care practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager provided information regarding staffing in the pre inspection information. There are currently fourteen care staff employed at the home this includes the deputy manager, night care and both fulltime and part time staff. There are also six ancillary staff including; an Accounts Manager, a Maintenance Person, two cooks and two house keepers (one of these is a vacant post). Staff rotas were seen and there are a sufficient number of staff on duty. The management and staff have worked hard to access and achieve the NVQ qualifications and as a staff group have exceeded the 50 minimum number of staff achieving Level 2. A number of staff have gone on to achieve the level Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 22 3. The deputy manager has also achieved the NVQ level 4 and the registered manager completed the Registered Managers Award. Also to be acknowledged are the cook and cleaner who have completed their respective NVQ qualification for ancillary workers. All staff who have not achieved the NVQ qualification have been enrolled and are working towards it. Four staff have left the home in the past year; three of these two care staff and one ancillary worker had achieved their NVQ qualification and moved on to further education or another job. A sample of staff records were seen and found to be well organised and in good order with a front sheet and dividers. Records for recruitment were comprehensive with a personal details sheet, employment history, health check and allergies / health questionnaire. Staff files seen held application forms, personal references, the required CRB checks and dates of employment. Copies of the code of conduct are issued to all staff. The registered provider / manager promotes and supports staff in training and development. In addition to the achievement of NVQ qualifications relevant all staff receive training in the safe working topics. Specialist training for meeting residents specific needs is provided such as; Dementia Care, Continence Management, Safe handling and administration of medication. The home provides an induction programme and evidence of this was seen in the staff records. Ten of the staff hold a current First Aid certificate. Only the deputy manager and three senior carers are trained and administer medication. The registered manager and deputy manager have successfully completed the training in Supervision Skills. The home is yet to develop a formal programme of staff appraisals. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. The operational management of the home remains under review as the staffing structure within the home develops. There are improved management and staff working relationships however it is essential that formal support is provided to staff through supervision and staff meetings. Similarly quality assurance and monitoring systems must be implemented effectively to demonstrate ensure the service delivery of care meets the residents needs. This judgement has been made using available evidence including a visit to this service. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered provider / manager has the NVQ level 4 qualification and since the last inspection visit has completed the Registered Managers Award. The registered manager worked closely with the previous deputy manager and between them they have made a considerable number of improvements to the operational systems in the home and the development of the staff team both in terms of their knowledge and care practice. The registered manager continues to participate in the training provided and accessed by the home and is involved in the day to day management of the home. As a management team they have developed a positive, open management style that has produced good team work and effective staff working relationships. The home has maintained a pleasant, sociable atmosphere in the home and this is beneficial for the quality of care provided for residents. The previous deputy manager was successful in achieving the NVQ level 4 however has been redeployed to senior care to focus on the direct work with residents. A new Acting Manager is due to be appointed and will provide cover for the registered manager as needed. The Administration systems in the home have improved both in terms of Staff files and Resident’s files and records. The home does have an accountant to complete the financial and business aspects of the home. The main office has been refurbished and efficiently organized to make information and systems readily available. The registered manager has produced feedback questionnaires and does periodically issue these to residents, their families and visiting professionals. A limited number are returned as yet the responses are not published. Resident’s meetings are held and their views sought particularly if there are any significant changes proposed. The cook regularly meets with the resident’s and records their preferences for seasonal menus. Key workers and senior carers take the lead with reviews of care plans and consult residents and their relatives regarding any change. The registered manager proposes to computerise the home’s systems and train staff in computer skills to update information. This will include a quality assurance and monitoring programme. As yet the home does not have a formal and effective quality assurance and quality monitoring system to measure the home’s success in meeting the aims, objectives and statement of purpose of the home. A sample of residents monies were seen and a discrepancy found in cash recorded and cash held. The previous deputy manager was able to explain this as money had not yet been issued to the hairdresser although it had been signed out. It was recommended that the record of income and outgoings Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 25 should be done as a running total every time a transaction is made. Receipts are kept and an audit of finances completed. The majority of residents or their relatives manage their own financial affairs. The management had completed training in supervision skills. The previous deputy manager had produced and begun a programme of regular supervisions sessions for all members of staff. However having stepped down to senior care worker this has not been implemented and there is no formal supervision of staff. There was evidence of files seen of new members of staff being issued the TOPPS induction pack. The safe working practice topics are being addressed through training for staff and implementation of policy and procedures. The pre inspection information provided by the registered provider / manager lists all the annual and other maintenance checks are complete and up to date for 2006 such as Legionnaires testing, Lift maintenance, Emergency call system, Central heating testing, PAT testing and the Five yearly electrical certification. Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 2 2 X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 27 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. 2. Standard OP20 OP22 Regulation 16(1&2c) 16(1) 23(2) Requirement The Responsible Individual must replace worn and or stained carpets. The Responsible Individual must ensure that an Assessment of the premises and facilities is undertaken by a suitably qualified person including a qualified Occupational Therapist; (Timescale of 2002 not met) The Responsible Individual must ensure the tear in the floor covering in the bathroom is repaired. The Responsible Individual and registered manager must ensure that all staff have an annual staff appraisal of their training and development needs. The Responsible Individual must provide an effective quality assurance and quality monitoring system to measure success in meeting the aims, objectives and statement of purpose of the home. The Responsible Individual and registered manager must ensure that all staff receive regular DS0000033323.V319262.R01.S.doc Timescale for action 31/03/07 31/05/07 3. OP21 23 31/03/07 4. OP30 18 31/05/07 5. OP33 24 31/05/07 6. OP36 18 30/04/07 Woodthorne Version 5.2 Page 28 supervision at least six times a year. 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 private service users with their relatives and for others where the statutory review has not taken place. Review and develop the range of activities available to people with dementia care needs and those with sensory impairments. The Registered Person / manager should provide an assisted bath on the first floor suitable to meet the assessed needs of service users. The Registered Person / manager should refurbish the bathrooms and shower rooms. The Registered Person / manager should review and risk assess the arrangements for furniture in Room 1. The Registered manager should keep a running total of income and outgoings with each transaction of residents money. 2. 3. 4. 5. 6. OP12 OP22 OP21 OP24 OP35 Woodthorne DS0000033323.V319262.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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.V319262.R01.S.doc Version 5.2 Page 30 - 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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