Inspection on 23/07/08 for Woodview Care Centre

This inspection was carried out on 23rd July 2008.

CSCI found this care home to be providing an Adequate service.

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

Woodview Care Centre 09/08/07

Woodview Care Centre 19/10/06

Woodview Care Centre 13/01/06

Woodview Care Centre 04/10/05

Woodview Care Centre 30/03/05

Woodview Care Centre 23/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Woodview Care Centre 127 Lincoln Road Branston Lincs LN4 1NT Lead Inspector Dawn Podmore Unannounced Inspection 23rd July 2008 09:30 X10029.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 Woodview Care Centre DS0000002563.V368772.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 and Care Homes for Adults 18 – 65*. 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. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodview Care Centre Address 127 Lincoln Road Branston Lincs LN4 1NT 01522 790604 01522 793478 woodview@schealthcare.co.uk The.willows@ashbourne.co.uk Exceler Healthcare Services Limited 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) Mrs Carol Yvonne Ritchie Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (42), Physical disability (21) of places Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To residents of the following gender: Either Whose primary care needs on admission to the home are: Old age, not falling into any other category - Code OP (maximum number of places 42) Physical disability - Code PD and Code PD(E) (maximum number of places 21) The maximum number of residents who can be accommodated is 63. 2. Date of last inspection 9th August 2007 Brief Description of the Service: Woodview Care Complex is located on the outskirts of Lincoln in the village of Branston. There are local services and facilities available within the village and transport links into the city of Lincoln. Accommodation is at ground level and is provided in two separate units, these are quite separate in purpose; both are managed by the same general manager and share some common facilities. There is car parking to the side of the building. The gardens are well kept and can be easily accessed by residents. Woodview Accommodation for Older People: 38 single bedrooms, 28 bedrooms with ensuite facilities, 10 without ensuite facilities, two double bedrooms, two lounges, and two dining rooms. Greenwood Accommodation for people with a Physical Disability: 21 single bedrooms, 1 lounge, 1 smoke lounge, 1 quiet room, 1 activity room, conservatory and one dining area. At the time of the inspection the manager stated that weekly fees ranged from £351 - £1711 depending on the residents assessed needs. Additional charges are made for services such as chiropody and hairdressing. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report is available in the reception area or the manager’s office. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection was unannounced and took any previous information held by C.S.C.I. about the home into account. The manager was available to assist with the inspection process. The main method of inspection used was called case tracking. This involved selecting a proportion of residents and tracking the care they receive through the checking of records, discussions with them and the staff who care for them and observation of care practices. A partial tour of the home was also conducted which included looking at some bedrooms, communal areas, bathing and toilet facilities. Documentation was sampled and the care records of four residents were examined. The Commission are trying to improve the way that we engage with people who use services so that we gain a real understanding of their views and experiences of social care services. During this inspection we used a method of working where an ‘experts by experience’ visited the home as part of the inspection to help us get a picture of what it is like to live in this service. The term ‘Experts by Experience’ used in this report describes people whose knowledge about social care services comes directly from using them. The experts met and talked to people over a 2 hour period visiting both units. We spoke with residents and relatives, as well as members of staff. They shared their views about how the home operated on a day-to-day basis and the care and facilities provided. Prior to the visit the providers had returned an Annual Quality Assurance Assessment (AQAA) and this document will be mentioned throughout this report. We sent out some ‘have your say’ surveys, six of which returned in time for their views to be included in this report. On the day of the visit 52 residents were living at the home. What the service does well: A warm and welcoming atmosphere was evident on entering the home. Staff were observed to interact with residents in a caring and friendly manner and assist them as needed. Staff were knowledgeable about peoples needs and could tell us about peoples individual preferences. Residents and relatives spoken with confirmed that the home was meeting people’s needs. They told us ‘they leave you to do it yourself, but are there if you need them’, ‘I am quite happy with everything’, Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 6 ‘the staff are very good, pleasant and nice young girls’ and ‘they come when I need them’. The activities organisers provide a varied programme of stimulation that people said they enjoyed. The home has detailed policies and procedures to inform residents and instruct and guide staff. What has improved since the last inspection? What they could do better: Risk assessments need to contain better detail about management strategies so that staff have clearer information about how to minimise identified risks. Some staff need to receive specialist training to meet the needs of the people they support, this includes subjects such as physical disabilities and conditions affecting older people. A structured induction programme for qualified staff should be introduced to demonstrate that they have received appropriate information about the operation of the home in relation to their role. Other areas that would benefit from some attention included the following. The Statement of Purpose and the Service Users Guide should be amended so that they provide current information. Information collated by the activities coordinator about peoples social and leisure needs should be included in a social care plan so that all staff have access to this information. Care plans should contain information about recent legislation that is designed to protect people’s rights and choices. This is so the home can show they have looked at the effects the legislation has on the resident’s lives and planned their care accordingly. The manager should assess people dependency levels, and the layout of the home, to assess and monitor the staffing levels being provided. This will help to ensure that enough staff are on duty to meet the needs of the people currently living at the home. The process for the investigation of complaints needs to be reviewed to ensure that investigations are timely and fully responded to. Woodview Care Centre DS0000002563.V368772.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. The summary of this inspection report can be made available in other formats on request. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People coming into the home have access to a range of information to help them make a decision about moving into the home. The home’s admission procedure includes an initial assessment, which helps to make sure that it can meet the needs of people admitted to the home. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide, which contain information about the aims and objectives of the home, as well as how it intends to operate. Some areas such as the contact details for the Commission were out of date, this means that people have not got access to up to date information. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 10 A review of all information available prior to this visit, including the content of the A.Q.A.A and records seen at the inspection in October 2007, showed that the home does not admit residents without a care needs assessment being undertaken. Two people spoken with during this visit confirmed that an assessment of needs had taken place prior to admission. The manager confirmed that 3 intermediate care beds were used as and when needed for spot contracts. The home does not have stairs and the only kitchen available is the communal one in Greenwood unit. This had been identified to the Intermediate Care Team prior to the contact being agreed. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs are being met by staff who understand their needs and deliver care in a respectful manner. Some care plans do not contain sufficient information to make sure that individual needs and preferences are always fully met. People are able to manage their medications themselves if they can, but if they need help staff are trained to support them with it in a safe way. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 12 EVIDENCE: We looked at the care records for 4 people living at the home, two from each unit. They contained information relating people needs, but the two from the older persons unit lacked detail about how people preferred their care delivering. For example one plan said to encourage the resident to be as independent as possible, but did not say what she was able to do herself, or how she preferred her care to be delivered. The two other files provided staff with good information about peoples needs and how they should meet them. Various assessments had been carried out regarding areas such as manual handling, nutrition and falls. Although assessments telling staff how to minimise potential risks had been carried out there were two areas that had not been fully documented. For example one plan said that the resident had requested bed sides be fitted, and they had been, but there was no risk assessment covering this topic. In both cases the care plan outlined the subject and gave staff some details about minimising risks, but this needed to be formalised in more detail. Assessments were completed before the visit ended. Regular monthly reviews of care plans had taken place and daily records were completed in good detail. The home has not yet included the content of the Mental Capacity Act in their care planning process. This is new legislation that is aimed at protecting people’s rights. Wound care was recorded in detail and included body maps and wound mapping charts. Staff had written about any injuries or wounds on the body maps, but the diagram of the body had not been shaded in to show the area affected. Records and peoples comments showed that health needs were being met with appropriate recording of GP, optician and chiropody visits. The A.Q.A.A. and the content of the last inspection report demonstrated that the home has satisfactory policies and procedures concerning the receipt, storage, administration and disposal of medications. On this occasion medication records were checked for the people being case tracked, these were all satisfactory. The expert by experience said that one person had told them that they sometimes felt rushed. She reported that people told her that although people’s needs were being met staff never had time to sit with them. Other people did not indicate that this was the case. One person told us, ‘they leave you to do it yourself, but are there if you need them’. Another said that she was quite happy with everything. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 13 Observations and staff comments demonstrated that staff had a good knowledge of the people they cared for. They were seen delivering care responsive to resident’s needs and preferences, as well as respecting their privacy and dignity. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home enables residents to maintain and develop social interests and relationships of their choice. They are able to make their own choices and have control over making decisions for themselves. EVIDENCE: Two activities coordinators are employed at the home, one for each unit. They provide a structured programme of activities for those who wish to participate. People said that they had been on outings such as shopping and to lectures. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 15 The notice board identified forthcoming events, such as a visit from the PAT dogs. Other events planned included, a summer fayre, a visit to Waddington air show and pub lunches. Resident’s files contained a social care profile, which provided staff with an insight into what sort of things residents were interested in. The new resident did not have a social care plan, but information about the resident’s interests was included in the activity file. The file also contained a record of what activities people had participated in. In the main people spoken with and those who completed surveys said that they were happy with the level of social stimulation supplied. The expert by experience said that people in the PD unit felt that everything had to be planned and nothing could be done spontaneously, as there was not enough staff on duty. However she also said that the notice board was full of things to do. Other people commented, ‘there is an activities programme from Monday to Friday, but I like to read, I get the books from the book trolley’, ‘I particularly enjoy the fish and chip shop night’ and ‘I’m not bothered with activities, but I do my exercises every morning at 5.30am’. Visitors told us that staff made them welcome at the home and that they could visit at any time. Some people felt that menus were varied and a good choice offered. But others told the expert by experience that they were not happy with the quality of the cooking on some days or the choices available. The AQAA says that the company use a rotating menu that has been assessed as nutritious; they offer 2 or 3 choices at lunch with alternatives such as jacket potato, omelettes and salads. One resident said that she had just had a gammon salad and had really enjoyed it. Another said that she had difficultly eating, but she was provided with a soft diet to help with this. A third said that she appreciated the fact that she had a choice of menu. If people could not help themselves staff were on hand to assist them, in the dining rooms or in their rooms. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear policies and procedures in place for handling complaints and allegations of abuse; this helps to safeguard the people living at the home. EVIDENCE: The home has a complaint procedure, which is displayed in the home and included in the Service Users Guide. Details contained in the AQAA and records held at the home showed that they had received 6 complaints since the last inspection. Records showed that these had been appropriately investigated and resolved, but only 66 had been completed within the timescales outlined in the home’s complaints policy. People spoken with confirmed that they knew how to make a complaint. Issues highlighted as causing concern included staff availability and food provided, these have been discussed in other sections of this report. People were complimentary about the staff and the way in which they delivered care. The home has procedures concerning the protection of vulnerable adults. The home has made 2 alerts to social services when they had concerns about the wellbeing of the people living at the home. Staff demonstrated a satisfactory Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 17 knowledge of what to do if they suspected abuse could be occurring and had received training in this subject. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a clean, comfortable and homely environment, but some areas are not well maintained and décor is worn. EVIDENCE: We took a partial tour of the home which included looking at the bedrooms of the residents being case tracked. Bedrooms had been personalised by the residents or their families with photographs, mementoes and small items of Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 19 furniture. People told us that they were happy with their rooms. One said ‘it’s lovely and I have a new carpet’ and another said, ‘I am very happy with my room’. New fire doors had been fitted, but these needed painting. Most corridors looked shabby and in need of redecoration and some carpets were badly stained. The manager said that these issues had been highlighted to the company and an action plan put together. Bathrooms were clean, but not homely in décor. One had been retiled and a new floor fitted, but it was stark and clinical in appearance. Three other bathrooms were cluttered with hoists, commodes and trolleys. The manager said that this was due to poor storage facilities and everything was moved out when they were in use. Various equipment was available including, hoists, specialist mattresses, raised toilet seat and grab rails. The expert by experience reported that she had noted an odour in two of the bedrooms, however other areas of the home were clean and odour free. Gardens, courtyards and the car park were well maintained with new facilities including a revamped area at the front of the building with seating. One relative commented that he thought the courtyard should have more things to encourage residents to go out more, such as a fountain. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are inadequate to maintain sustained and regular levels of care to individual residents. Procedures for the recruitment of staff were robust and therefore offered protection for people living at the home. Specialist training provided to staff is inadequate which means that there is a risk that residents needs will not be met. EVIDENCE: Records and people comments showed that there were occasions when the home had not provided the planned number of staff on duty. Agency staff had been used to fill in for absences, but there were occasions when extra staff could not be arranged. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 21 People living in Greenwood told the expert by experience that they could not do things spontaneously due to lack of staff. Some residents in Woodview told her that although their needs were being met staff were sometimes rushed and did not have time to sit and talk. Although dependency assessments were included in resident’s files the manager had not used this information to assess and monitor the staffing levels to make sure that there was enough staff on duty to meet people needs. Staff spoken with and those who returned surveys told us, ‘we are always working on the minimum, which is a constant strain’, ‘it’s okay when it is quiet but when it’s busy bells ring a lot’, ‘sometimes a problem if staff report sick and we have to work short’, ‘there was a blip before Christmas but it seems to be okay now’ and ‘sometimes we run very short of staff and only basic care can be given, it should be based on dependency not just numbers’. Recruitment of new staff was being carried out correctly with essential checks such as written references and C.R.B. (Criminal Records Bureau) checks being undertaken. Records demonstrated that new care staff receive a satisfactory induction to the home. However there is no structured induction programme for qualified staff. The reasons for documenting that new nurse’s have been made aware of key procedures, such as administration of medication, reporting safeguarding incidents and contacting doctors were discussed with the manager. Staff said that they felt well trained and supported. The company have a good programme in place to ensure staff received mandatory subjects. However staff comments and records failed to demonstrate that specialist training had been provided both in older peoples conditions and for physical disabilities. Neither had awareness training regarding recent legislation, such as the Mental Capacity Act taken place. Training undertaken included manual handling, medication updates, first aid, and fire awareness. The company encourage staff to complete an N.V.Q. (National Vocational Qualification) in care. Records and staff comments confirmed that out of 44 care staff 22 have completed an NVQ and 4 are currently completing the award. Observation of care practices at the home demonstrated that staff were caring for people in an appropriate manner. People told us that they were happy with how care was delivered at the home. They said that staff were ‘very good, pleasant and nice young girls’, ‘good, no issues’ and ‘they come when I need them’. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s management structure provides guidance and direction to staff to ensure that care is delivered in a consistent manner. The home is managed in the best interests of the residents. There are systems in place to ensure that the health, safety and welfare needs of residents are met. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager was registered with the Commission in May 2007. She is a qualified nurse with experience in care management. She receives regular support and supervision from her line manager. Residents and visitors said that they were happy at the home. One person told us, ‘I am very happy with everything’. Another resident told the expert by experience that it was the best place around for respite care as he had been to several other homes and he was happy to be there as it was near his home too. The expert by experience also commented that she found the feel of the home to be friendly and the staff gave respect to the people they were assisting. One member of staff said, ‘the manager is approachable’. Another commented, ‘she comes out regularly to see residents and staff, and we have meetings’. The company has a quality assurance system so that it can gain the views of people who use the service and ensure that the systems in place are being followed. We reviewed the results of surveys returned in 2007, which showed that the majority of people were happy with the care they received. Half of the people surveyed said that they did not like the food at the home but the manager said that this had been addressed. The company also has an audit system, which is used to assess if staff are following procedures correctly, this includes the auditing of care plans. At the last inspection there was a satisfactory system in place for resident’s monies to be held in safe keeping by the home. This includes keeping a running total of all transactions and obtaining receipts and signatures. It was confirmed that there had been no changes to the system being used. The Company have a range of health and safety policies and procedures available to guide and instruct staff. There is a programme in place to service and maintain equipment in the home on a regular basis. Information provided in the AQAA, demonstrated that regular checks on equipment such as hoists and fire fighting equipment had taken place. A visit by the Environmental Health Officer in February 2008 had resulted in the kitchen being awarded a 5 star rating for cleanliness and facilities. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 3 4 X 5 X 6 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 (1) Requirement Care plans must contain detailed information regarding people’s needs and preferences, including their social needs. This will help to ensure that staff have the right level of information to be able to deliver care and support in a person centred way. Risk assessment documentation needs to provide better information about minimising risks associated with peoples care, as this will provide staff with clearer information about how to meet their needs. Development has taken place since the previous inspection however further attention is required to fully comply with this requirement. There must be sufficient staff on duty to provide sustained and regular levels of care to individual residents. This must take into account the dependency levels of people living at the home to ensure that they are adequate to meet the needs of the residents. DS0000002563.V368772.R01.S.doc Timescale for action 01/10/08 2. OP7 13 (4) 29/09/08 3. OP27 18(1)(a) 01/09/08 Woodview Care Centre Version 5.2 Page 26 4. OP30 18 Staff must receive specific training to meet the needs of the people they support. A structured induction programme must be developed that demonstrates that qualified staff have received all the information they need to enable them to carry out their role. 01/01/09 5. OP30 18 01/10/08 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 that support plans include reference to the Mental Capacity Act, 2007 and the effects it has upon the service users lives. This is to ensure that their rights and choices are protected. Woodview Care Centre DS0000002563.V368772.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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