Inspection on 09/06/08 for Woodville Rest Home

This inspection was carried out on 9th June 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

Woodville Rest Home 12/06/07

Woodville Rest Home 19/06/06

Woodville Rest Home 27/02/06

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

CARE HOMES FOR OLDER PEOPLE Woodville Rest Home 8-10 Woodville Road Bexhill-on-sea East Sussex TN39 3EU Lead Inspector June Davies Unannounced Inspection 9th June 2008 10:15 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 Woodville Rest Home DS0000062808.V365630.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. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodville Rest Home Address 8-10 Woodville Road Bexhill-on-sea East Sussex TN39 3EU 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) 01424 730497 01424 736479 Pages Homes Ltd Nina Cooper Care Home 17 Category(ies) of Dementia - over 65 years of age (17) registration, with number of places Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is seventeen (17) Service users must be older people aged sixty-five (65) years or over on admission Service users with a dementia type illness only to be accommodated Date of last inspection 12th June 2007 Brief Description of the Service: Woodville provides residential and social care for seventeen older people with a dementia-type illness. Currently, the home cares for one resident who does not have a dementia-type illness. The home is a detached property, set in a quiet residential area of Bexhill-on-Sea, close to Egerton Park, the seafront and the town centre. Residents’ accommodation is provided on two floors and there is a stair lift to access the first floor. There are 11 single bedrooms and three bedrooms registered for double occupancy. Seven of the service user’s rooms have en suite facilities. The home provides a lounge with a dining area. with a sun lounge at the rear of the property. There is a small rear garden The current scale of weekly charges ranges from £423.00 to £580.00 per week and there are extra charges for hairdressing, chiropody, newspapers, magazines and toiletries. The registered proprietor has recently obtained planning permission to extend the home for a further five en suite bathrooms and to demolish the summerhouse. Work on the extension to due to start in September 2008. The inspection report is on display in the front entrance and included in the statement of purpose. Woodville Rest Home DS0000062808.V365630.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 carried out over a period of 7 hours on Monday 9th June 2006. The inspector spoke with the registered provider, registered manager, deputy manager, cook and one resident. During the course of this key inspection the inspector carried out a tour of the premises, looked at all documentation relevant to the standards inspected, observed a lunch time meal, observed a medication round and carried out an audit of the medication within the home. Residents living in the home a high level of dementia or Alzheimer’s disease, none of the residents with the exception of one have the capacity to converse about the level of care they receive and their daily social lives. One resident said, ‘I like being here. The food is nice and it is tasty.’ What the service does well: Woodville Rest Home provides comfortable well-furnished accommodation for the residents who live there. The residents have free access to a safe and secure back garden. Prospective residents their relatives/representatives are provided with detailed information about the home and the service it offers. Prior to a resident moving into the home, thorough pre-admission assessments are obtained to ensure that the home can meet the prospective residents needs, and the staff have the experience and qualifications to meet those needs. Care plans in themselves are good and based upon information gained during the pre-admission assessment. There is some evidence of good multi disciplinary working. Medication is well managed in the home, and only trained staff are permitted to administer medication to the residents. During the inspection staff showed that they were caring, and in most cases respected the privacy the dignity of the residents. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 6 There are a variety of social activities on offer to the residents, and the manager is continually looking for further activities that would be appropriate for the residents to participate in. Community contact for the residents is good. Over 50 of staff have obtained their National Vocational Qualification. What has improved since the last inspection? What they could do better: Residents must each have their own daily report sheet or diary, and names must not be kept collectively. Staff must ensure that all personal hygiene tasks are recorded daily, and that records must be kept for each resident of any external health care visits, this must include district nurses, general practitioners, chiropodists, opticians, dentists, and community psychiatric visits. Residents’ who have developed pressure areas, should be turned regularly and this should be recorded. All residents should be weighed on a regular basis on scales that are fit for the purpose, and able to meet the physical needs of the residents. All food must be presented to the residents in an appetising way, and where residents needs assistance from care staff this should be done in a discreet and sensitive manner. The complaints policy and procedure should be displayed within the home to ensure that residents’ their relatives/representatives and other visitors know the procedure should they need to make a complaint. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 7 The registered manager must ensure that the Abuse policy and procedure gives staff full details of the types of abuse, and signs to watch out for if abuse does occur. The registered manager should obtain a copy of the Sussex MultiAgency Policy for Safeguarding Vulnerable Adults. The home does need an industrial washing machine that has a sluicing programme and meet the disinfecting requirements. The home must be kept free of offensive odours at all times. Recruitment practices in the home are poor at the present time, and a stringent recruitment practice must be set up to comply with the Care Homes Regulation 2001, Schedule 2, this is to ensure that residents are not placed at risk. Some staff still need to undertake or update mandatory and work related training, to ensure they have the knowledge and skills to meet the residents needs and ensure that residents are placed at the minimum risk. While the quality assurance system that has been developed is good, some further work needs to be done to ensure that residents are receiving a high quality of care throughout. Residents’ records must not be left in communal areas of the home, and should be kept securely in the home for confidentiality purposes and to meet with the Data Protection Act 1998. Risk assessments should be carried out for each bedroom that has a bath in it’s en-suite facilities, to ensure that residents are not placed at risk. Residents bedroom doors should not be wedged open for their safety should a fire occur in the home. 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. Woodville Rest Home DS0000062808.V365630.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 Woodville Rest Home DS0000062808.V365630.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): Standards 1, 2 and 3 People who use this service experience good quality outcomes in this area. The homes Statement of Purpose and Service User Guide provide residents and prospective residents with the information they need to make a decision about moving into the home. Each resident is given a contract when moving into the home, which states the number of the room they will occupy and the fees, as well as who will be responsible for payment of the fees. Residents move into the home knowing that their needs can be met and that their independence will be maximised and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 10 The homes statement of purpose and service user guide has now been updated and contains the correct information as required under standard one of the National Minimum Standards. The registered manager is in the process of devising a pictorial copy of the service user guide, to ensure that residents with dementia or Alzheimer’s are given more opportunity to understand what Woodville Rest Home is able to offer them. A copy of the statement of purpose and service user guide is in place in each resident’s bedroom and a copy is also available in the front entrance hall. Each resident has a statement of terms and conditions given to them when they come to live in the home, this contract states the number of the room they will occupy and what fee will be charged and by whom it will be payable. In most cases these contracts are signed by the resident’s relative/representative. This was evidenced by viewing the contract of the most recent resident who had come to live in the home. The registered manager always carries out her own pre-admission assessment prior to a resident moving into the home. Where a resident is going to be funded by a local authority the registered manager also obtains a care manager plan of care or assessment of needs. The inspector viewed the preadmission assessment for the newest resident and found it to contain detailed information as to the care needs of that resident. The registered manager also tries to obtain detailed life histories from resident’s families prior to them moving into the home. The home does not offer intermediate care. Woodville Rest Home DS0000062808.V365630.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): Standards 7, 8, 9 and 10 People using this service experience adequate quality outcomes in this area. The care planning system is good for residents but daily records need to be improved upon so that reviews can accurately reflect the care needs of the residents. The health needs of residents are well met with some evidence of good multidisciplinary working taking place on a regular basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans are initially based upon the pre-admission assessment obtained by the registered manager and plans of care sent by the care manager prior to the resident moving into the home. From the three care plans viewed by the inspector all contained detailed information regarding personal, social and Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 12 physical care needs of the residents. All care plans have a generic mobility risk assessment, and one care plan viewed contained a risk assessment relating to tissue viability. A further individual risk assessment needs to be drawn up regarding the use of cot sides. The registered manager stated that the resident’s family purchased the cot sides for their mother to use, but there was no evidence of recorded permissions within this care plan. From discussion with the registered manager she agreed to request that the family does sign a permissions form for the use of these cot sides. All the care plans seen showed that senior members of staff review them monthly. The member of staff reviewing the care plan writes up a monthly report, and this is then placed into the plan of care. Due to the level of dementia and Alzheimer’s disease, none of the residents would be able to sign up to their plan of care, or agree monthly review changes. The registered manager should request that relatives/representatives sign up to the care plan and reviews. The inspector viewed two diaries one for night staff and one for day staff. On viewing these dairies it was found these were being used a daily reports on the residents, and names were being kept collectively, this contravenes the Data Protection Act 1998. Separate daily records should be kept for each individual resident and a requirement is being made in relation to this. The diaries showed staff recording for each resident as bathing and dressing carried out, but was not specific in regard to other personal care tasks, e.g. cleaning dentures or teeth, nail care, checking tissue viability, shaving and hair care. It is in the homes interests to keep detailed daily records to be able to show what they have done, along with providing evidence on which to base the monthly review and to record that the staff are following the assessment of needs. Two residents at the present time have pressure areas, district nurses have been informed, and have provided staff with dressings, and have told staff if they have concerns to contact them. One resident has a pressure-relieving mattress, and spends many days at a time in bed. There was no evidence to show that either of these two residents had a turning chart in place and a requirement has been made to ensure that the registered manager puts a turning chart in place for staff to use when these residents are turned. There was evidence within the care plans that the home has regular contact with the continence nurse, and many of the residents are supplied with continence aids. Some of the care staff have also been booked onto a continence course. It is important that all visits from the continence nurse are recorded in the resident’s professional visits page in his or her care plan, or recorded onto daily reports. On the day of the visit one resident had a visit from a community psychiatric nurse. The registered manager stated that where there are any concerns Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 13 regarding a resident’s mental well being, this is referred in the first place to the general practitioner who in turn will make a referral to the psychiatric consultant. Where possible nutritional screening takes place, but some of the residents are unable to stand on scales, and there was once instance within a care plan where nutritional screening had not taken place for several months because the resident was not able to stand on scales. A requirement is being made that the registered provider supplies the home with sit on scales to ensure that all residents are weighed on a regular basis. One resident is causing the home some concern in that she is not taking nutrition regularly due to sickness; this has been reported to the general practitioner, who is reluctant to pursue this. Staff ensure that the residents’ general practitioner is informed of any health matter that is causing them concern. Residents have access to other health care professionals such as opticians, dentists, and chiropody, but this is not always recorded onto the professional visits page in the care plan. The inspector carried out an audit of medication. The home has up to date policies and procedures for the receipt, recording, storage, handling, administration and disposal of medication. The inspector observed a lunchtime medication round and found that medication is administered appropriately and that MAR sheets are correctly signed off. All medication brought into the home is properly recorded onto the MAR sheets, with date of receipt, amount of medication and signature of member of staff receiving the medication. At the present time the home does not use controlled drugs, but there is a controlled drugs box, securely fitted to the wall inside a locked cupboard. All eye drops are dated on the bottle on the day they are opened. All staff administering medication have received training. It was noted that one or two liquid medication bottles are sticky, this was discussed with the manager regarding the possibility of staff using a wet cloth or wipes after dispensing this medication to keep bottles and medication trolley clean. None of the residents are able to administer their own medication. During the course of the inspection the inspector observed that the majority of staff on duty respected the privacy and dignity of the residents. Doors are kept shut while personal care is carried out. One resident has her own private telephone, and this facility is open to other residents if requested. Visits from General Practitioners and District Nurses are carried out in the resident’s own bedroom. The home has three double bedrooms and all are provided with curtain screening around the beds. On the day of this inspection the hairdresser was visiting the home, and a resident’s bedroom on the ground floor was being used as a hairdressing room. The resident whose bedroom was being used was not able to make an informed decision about her room being used as a hairdressing room, there are other facilities in the home which Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 14 could be used for hairdressing, therefore a requirement is being made that residents privacy and dignity is respected this applies to using residents bedrooms for other purposes. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 15 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): Statements 12, 13, 14 and 15. People using this service experience good quality outcomes in this area. Activities and links with the community are good and support and enrich the residents’ social lives. The home has an open visiting policy and visitors are welcome in the home at any time. Residents are helped where possible to exercise choice and control over the lives. While meals in the home are good, more attention needs to be paid to detail with liquidised food and assisting residents in eating. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 16 The registered manager has ensured that residents have a variety of social activities on offer such as board games, arts and crafts, baking, puzzles and walks to the park, the sea front and into town. The registered manager and deputy manager stated that they are always looking for new activities that residents can participate in that are relevant to meeting the needs of residents with dementia and Alzheimer’s disease. On the afternoon of the inspection some residents were taken for a walk to the local park. Residents are able to choose when they get up and go to bed. The registered manager has also organised entertainment and activities from people outside the home including ‘Motivation Co.’ every two weeks and church singers who visit the home every month. The home does not have communion services, but one resident is able to go to her local Methodist church and another resident receives newsletters from the Celtic Orthodox Church. Sometimes residents are taken into Bexhill to do personal shopping for clothing and toiletries so they may select the clothes and toiletries they like. Some of the care staff in the home are doing an Activities course on the 3rd July 2008. The home has an open visiting policy and visitors are welcome in the home at any time. None of the residents have the mental capacity to manage their own personal financial affairs and relatives/representatives have power of attorney and manage finances on their behalf. Should an advocate be required the registered manager would know who to contact on behalf of the resident or their relative. From a tour of the home many of the residents have been personalised with their own furniture and personal possessions, such as, photographs, cuddly toys, pictures, ornaments and silk flowers. The inspector was present in the dining room at lunch time, only one resident was able to enter into conversation regarding her meal, saying ‘Food in the home was good, and that her meal was tasty. The lunch offered to the residents during this inspection was – savour minced beef, mashed potatoes, peas, sweet corn and carrots, some residents had chosen the choice menu of tuna fish with salad. The home has a four-week rotating menu with choices available at each meal. Some residents require liquidised meals and the cook ensure that each item of food is liquidised separately to ensure that the meal is presented in an attractive and appealing manner. It was noted however that a member of staff was then mixing the liquidised food up prior to feeding it to the resident. This member of staff was also standing over the resident to feed them, and a requirement is being made that liquidised food is presented to the resident in an appealing and appetising manner, and that staff offer residents assistance in a discreet and sensitive manner. The home can cater for specialised diets, but at the present time only cater for diabetic diets. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 People using this service experience adequate quality outcomes in this area. The introductory documents contain the complaints policy and procedure but this policy is not displayed in the home. Some of the staff have knowledge for protection of residents’ from abuse, but the documents in the home do not give clear guidelines as to what the forms of abuse are. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy and procedure has recently been reviewed and is included within the statement of purpose and service user guide, but is not displayed within the home. The registered manager has a complaints file. There have been no complaints made to the home since the last inspection. The safeguarding vulnerable adults policy and procedure has recently been reviewed, but while stating the different types of abuse does but these are not detailed, and therefore the policy and procedure needs to be written in more detail. The registered manager does not have the Sussex Multi-Agency Policy and Procedures for Safeguarding Vulnerable Adults. A requirement is being Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 18 made to ensure that the home has up to date information for staff regarding the Safeguarding of Vulnerable Adults. 46 of care staff have received Protection of Vulnerable Adults training. There have been no adult protection issues since the last key inspection. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 19 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): Standards 19 and 26 People using this service experience good quality outcomes in this area. Recent investment has improved the appearance of the home and further improvement will enhance the residents’ quality of life. Infection control issues are generally well managed in the home, but further improvements need to be made to ensure that the home is free of offensive odours. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last key inspection improvements have been made to the home, and now the home provides a comfortable homely place for residents to live in. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 20 The registered manager has employed a maintenance man, who carries out day-to-day maintenance as required, and also decorates bedrooms as they become vacant. The registered provider has recently had planning permission granted for an extension of five bedrooms, a new office and new laundry room will be developed and the summerhouse, which is a poor state of repair and decoration, will be demolished. The inspector carried out a tour of the building and found that bedrooms, the furniture and fittings were in good order. The laundry room is incorporated at the rear of the summerhouse at the present time, and has three domestic washing machines and an industrial tumble drier. There is no sluicing facility in the home or on the domestic washing machines and therefore a requirement is being made that there is a washing machine with appropriate sluicing facility within the home. The laundry room was clean, flooring needs replacing but as this room is due to be replaced no requirement is being made at this time. A clini bin is provided for clinical waste, and is fitted with the appropriate bag; staff empty this frequently to avoid odours. Some parts of the home did have an offensive odour and the registered manager is aware of this and recognises that further work needs to be done in promoting residents continence needs. 60 of care staff have received infection control training. Woodville Rest Home DS0000062808.V365630.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): Standards 27, 28. 29 and 30 People using this service experience poor outcomes in this area. Staffing levels, the qualifications of staff and training ensure that residents’ needs are met. Recruitment practices are poor and this leaves the residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the present time there are 15 residents residing in Woodville Rest Home. Staff rotas together with observation and talking to staff showed that the care staffing levels were sufficient to meet the personal, physical and social care needs of the residents. The home employs sufficient ancillary staff for cooking and maintenance within the home. Domestic cleaners are contracted via a cleaning company and come into the home 7 days a week to do cleaning, where carpets need shampooing the contract cleaners come back into the home on the same day to do this. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 22 The staff in the home felt they had sufficient time to do personal tasks for the residents as well as activities. The registered manager is well aware that she needs to keep staffing levels under constant review to ensure that sufficient staff are employed on each shift, to meet the needs of the residents. 53 of staff have achieved their NVQ level 2 or above, with a further 2 staff in the process of working towards their NVQ and a further two staff waiting to enrol on the course. This meets the National Minimum Standards. Three staff recruitment files were viewed and there are concerns in regard to the recruitment of staff at the present time. The registered provider uses an employment agency for overseas staff, but does not ensure that this agency provides him with an application form, two written references and appropriate Criminal Records Bureau checks and checks against the Protection of Vulnerable Adults register, none of the files viewed had any form of identification. Therefore the inspector is making a requirement to ensure that the home operates a stringent recruitment procedure and obtains information as required by Schedule 2 in The Care Homes Regulations 2001. This requirement was made at the previous inspection on the 12/06/07 and the timescale for compliance has not been met. Further non-compliance will mean that enforcement action is taken. Many of the staff have attended health and safety related training – moving and handling 70 , Infection control 60 , Fire Safety 60 , Food Hygiene 60 , First Aid 53 as well as work related training – Medication 98 and Dementia awareness 40 . There is a good up to date training matrix in place, which is updated whenever staff take part in training. The registered manager must ensure that further training is provided to ensure that all staff have received training in the above courses, to ensure they have the skills and knowledge to ensure the health, safety and awareness of residents living in the home. All new staff receive basic induction as well as ‘Skills for care induction.’ The registered manager is attending a training day to increase her knowledge of ‘Skills for Care’ induction. Woodville Rest Home DS0000062808.V365630.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): Standards 31, 33, 35, 36, 37 and 38 People using this service experience adequate quality outcomes in this area. The registered manager has a good understanding of what needs to improve in the home to ensure that residents received a good quality of care. There is a good quality assurance system being developed in the home and this also ensures that the quality standards for residents are being closely monitored. Further improvements needs to be made to maintaining the confidentiality and security of records in the home. Health and safety issues are generally well maintained but further improvements need to be made to ensure that residents are not placed at risk. This judgement has been made using available evidence including a visit to this service. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager has achieved her Advanced Vocational Certificate of Education in Health and Social Care, National Vocational Qualifications levels 2 and 3, Registered Managers Award and Assessors A1 qualifications. The registered provider has also obtained NVQ level 4 and RMA. The manager has worked hard to improve the home since the last inspection and recognises there are still further improvements to be made. Her deputy manager supports her in this. The registered manager operates an open door policy in the home ensuring that while on duty she is always available for residents, visitors and staff. The registered manager has worked hard at producing a good working quality assurance system in the home. The views of new residents, residents, visitors and staff are sought via questionnaires. There is an up to date Development Plan for the home. The registered manager has carried out a Health and safety and fire risk assessment of the whole building, and quarterly she monitors fire alarm checks and nurse call system. Resident falls are monitored on a monthly report sheet. The regulation 26 visits carried out by the registered provider do not contain sufficient information to ensure that quality standards are being met. The registered manager needs to further develop this quality assurance system to ensure that care plans, daily reports, reviews, medications have a recorded monitor once a month, and that cleaning and the presentation of food is also monitored on a monthly basis. At the end of the year the registered manager should then produce a written report of her quality assurance findings for the whole year. None of the residents have the capacity to manage their own personal allowances, but purchases are made on their behalf, receipts are retained the registered provider then bills the relatives/representatives on a monthly basis. Where the home is going to make large purchases on a resident’s behalf, the relative/representative brings the money into the home, a receipt is signed and when the purchase is made a receipts is kept of the purchase with any change and the receipt being returned to the relative/representative. There was evidence within the staff files that the registered manager carries out at least six recorded formal supervisions of all staff during the course of the year. During these supervisions sessions the philosophy of the home, national minimum standards, and training needs are discussed. Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 25 It was noted that during the course of this key inspection, diaries kept for daily reporting on the residents are kept openly in the communal dining room and are available for anyone to look at. Daily records must be kept separately for each resident in a secure place to ensure confidentiality, and in accordance with the Date Protection Act 1998. Part of this is referred to earlier in the report under Health and Personal Care. A requirement is being made that all information kept relating to residents is kept in a secure place in the home and is only available on a need to know basis for staff working in the home. As mentioned under staffing in the report, there are still some staff that need to complete their mandatory training in health and safety issues. During a tour of the home the inspector noted that some bedroom doors are propped open, and none of the bedroom doors or fire doors are fitted with magnetic closures, that would activate should the fire alarm sound. A requirement is being made to ensure compliance, that the Fire Safety Office must be consulted regarding the wedging open of residents’ bedroom doors. Radiators throughout the home are covered, and pipe work is minimal with all pipes running under the floor. All windows are fitted with window opening restrictors. Several bedrooms in the home have en suite facilities, some have baths in these en-suite facilities, bearing in mind that this home is registered for dementia care, these en-suites should be risk assessed to ensure that residents are not being placed at risk, and to ensure that the level of risk is kept to a minimum. All incidents and accidents are properly recorded within the accident book, and the manager also completes a monthly falls record. The falls record ensures that residents are not placed at risk and gives the manager good information as to the time of the falls, and the place where most falls take place. Woodville Rest Home DS0000062808.V365630.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 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 1 2 Woodville Rest Home DS0000062808.V365630.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. Standard OP7 Regulation 17 Schedule 3 Requirement The registered manager must ensure that all records are kept separately for each resident this includes daily records. To keep information collectively contravenes the Data Protection Act 1998. The registered manager must ensure that staff record all personal hygiene tasks carried out for the residents, daily records when well written, help to ensure a consistent approach and good quality of care for service users. Detailed daily records will help the registered manager audit the care being provided to residents, and ensure that staff are following the guidelines in the care plans. Timescale for action 08/08/08 2. OP7 15 (2)(b)(c) Schedule 3 (1)(b) 08/08/08 3. OP8 14 (1)(a) (2) 17(1)(a) The registered manager must also ensure that visits from external health care professionals to resident(s) are also recorded within the care plans or daily reports. The registered provider must 08/08/08 ensure the home has appropriate scales on which the residents’ DS0000062808.V365630.R01.S.doc Version 5.2 Page 28 Woodville Rest Home 4. OP15 12 (1) 16 (2)(i) can be safely weighed on a regular basis, to ensure their nutritional requirements are being met. The registered manager must ensure that liquidised food is presented in an appetising and appealing manner at all times. 08/08/08 5. OP18 12 (1)(a) 13(6) 21 6. OP26 13(3) 16(2)(e) (f)(j) 7. OP26 8. OP29 12(1)(a) 13(3)(4) (a-c) 16(1)(2) (j)(k) 23(1) (a –d) 19 (1) (a – c)& (2 – 7) Schedule 2 The registered manager must also ensure that where staff need to assist resident with feeding this is carried out in a discreet and sensitive manner. The registered manager must 08/08/08 ensure that a detailed policy and procedure is available to ensure that staff are supplied with the knowledge of the different kinds of abuse and what actions they should take if they suspect abuse has occurred. The registered provider must 22/08/08 ensure that an appropriate washing machine is provided that will thoroughly clean foul laundry and have a specified ability to meet disinfection standards. The registered manager must 22/08/08 ensure that the home is kept free from offensive odours at all times. The registered provider must 08/08/08 ensure that the home has rigorous recruitment practices to ensure that all staff employed, produce and up to date application form (with full employment history), names and addresses of to written references (one must be from their previous employer), evidence that these references are followed up, an up to date DS0000062808.V365630.R01.S.doc Version 5.2 Page 29 Woodville Rest Home 9. OP37 17 (1 – 3) 10. OP38 23 (4) The registered manager must ensure that all records relating to residents are kept securely in the home to maintain confidentiality and ensure that the meet with the Data Protection Act 1998 The registered manager must ensure that the fire officer be consulted regarding bedroom doors that are wedged open 08/08/08 08/08/08 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 OP8 Good Practice Recommendations It is good practice to ensure that those residents’ who have pressure areas are turned on a regular basis, and that a recording system is in place to ensure that regular turning is carried out. The complaints policy and procedure should be displayed within the home. The registered manager must ensure that all staff continue to receive mandatory and work related training, and therefore further training courses must be booked to ensure this. The registered manager needs to ensure that the quality assurance system being developed in the home incorporates monitoring of all systems used in the home, and that an annual report is published to highlight areas of good quality care and those that need improving on within the coming year. The registered manager needs to ensure that risk assessments are in place for those en-suite units that have baths in situ, to ensure that residents are not placed at risk. 2. 3. OP16 OP30 4. OP33 5. OP38 Woodville Rest Home DS0000062808.V365630.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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