Inspection on 31/10/07 for Woolnough House

This inspection was carried out on 31st October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woolnough House 24/09/08

Woolnough House 28/11/06

Woolnough House 29/03/06

Woolnough House 06/12/05

Woolnough House 24/02/05

Woolnough House 10/08/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Woolnough House Woolnough House 52 Woolnough Avenue Tang Hall York North Yorkshire YO10 3RE Lead Inspector Jean Dobbin Key Unannounced Inspection 09:00 31st October 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 Woolnough House DS0000034896.V333778.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. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woolnough House Address Woolnough House 52 Woolnough Avenue Tang Hall York North Yorkshire YO10 3RE 01904 413656 01904 431755 EPHwoolnough@york.gov.uk www.york.gov.uk City of York Council 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) vacant post Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2006 Brief Description of the Service: Woolnough House provides personal care and accommodation for up to 35 older people and is owned and managed by City Of York Council. Nursing care is not provided. Woolnough House was purpose-built approximately 40 years ago and is located in the Tang Hall area, to the east of the city. There is a regular bus service to the city centre, which is about 2 miles from the home. There are nearby shops and public houses. Accommodation is provided in single rooms on two floors. The upper floors are accessed by a passenger lift. There is a small car park to the front of the home. Details provided in September 2007 state that the weekly fees are £432. Additional charges are made for hairdressing, chiropody services and individual items like toiletries. The service provides an information booklet about the home to prospective residents. The Statement of Purpose and service user guide, which gives information about the home is available, with a copy of the latest inspection report, for people to read. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is what was used to write this report. • • • Information about the home kept by the Commission for Social Care Inspection. Information asked for before the inspection. This is called an Annual Quality Assurance Assessment (AQAA). Information from surveys, which were sent to people who live at Woolnough House, their relatives, and other professional people who visit the home. 10 were sent to people at the home and 7 were returned. 3 were sent to people’s relatives and 2 were returned. 3 were sent to GPs, 3 to care managers and 1 to a healthcare professional and 2 were returned. 3 were sent to staff members and all were completed and returned. A visit to the home by one inspector, which lasted about 7.5 hours. This visit included talking to people who live there and their visitors, and to staff and the manager about their work and training they had completed. It also included checking some of the records, policies and procedures that the home has to keep. • Information about what was found during the inspection was given to the general manager at the end of the visit. What the service does well: The manager is enthusiastic, with lots of ideas, and has made a number of changes for the benefit of the people living there. One person commented in their survey “the home is a happier place under its present manager”. Staff are beginning to gather detailed information about people’s likes, dislikes and interests so that support can be tailored to their individual needs and goals. The keyworker system, whereby the same carer helps with bathing or showering and other tasks, means that close relationships can be established between the individual and carer. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 6 Although the main meals are prepared away from the home the manager has introduced ways to adapt the meal provision so that people can receive more appropriate foods according to their individual needs. Staff are provided with a variety of training opportunities so that they have more knowledge and skills to support the people living there. One staff member said there was “lots of training available”. The manager has introduced ways to allow people to have a say in how the home operates. One person commented “the home has something for everyone and feels like a residence rather than an institution”. What has improved since the last inspection? What they could do better: The way ‘risk’ is managed at the home could be reviewed. Those people assessed as ‘at risk’ could have a plan in place describing how that risk is to be managed and minimised. These assessments could be properly reviewed, both regularly and following any event that affects that person. This is so that people can be kept as safe as possible, whilst recognising their right to take risks. Some records describing the care that people need could be improved to say how the home plans to support them to remain in control of their lives as far as possible. These could then be checked regularly as a way of making sure they remain to a good standard. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 7 The documentation relating to contacts with healthcare professionals could be improved so that it is easier to work out when a discussion about an individual or a visit from a healthcare professional last took place. This would contribute to showing that people’s healthcare needs are being met. The way medication practices work at the home could be looked at to see if changes could improve these practices and make them safer and more robust for the people living there. The system to stop people from walking into the laundry room and possibly being harmed could be improved. 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. Woolnough House DS0000034896.V333778.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 Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People who use this service experience good quality outcomes in this area. People can be reassured that they will be assessed prior to moving to the home so that they know that their needs can be met. These assessments could be better used so that people’s plans of care will be appropriate to meet their needs. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People expressing an interest in moving to the home receive a booklet describing the services and facilities offered at the home, and are also invited to spend a day at the home. A review meeting is held six weeks after moving there to check that everything is satisfactory. All people are assessed prior to moving to the home. Two people, the manager and a care leader usually complete this. This is done so that the Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 10 person’s physical, emotional and social needs can be discussed. The manager can check that the home has the facilities and the staff have the skills to support the person properly. The assessment also helps the person to decide if they want to move to the home. The care manager also completes a comprehensive assessment. Three people’s care files were looked at. Only two of these contained assessments by a care manager. Staff were unable to locate the third assessment. One of these people had moved to the home recently, and whilst the manager could remember completing her own assessment for this person, this also could not be found. The manager was able to show assessments she had completed for other people living there. The record keeping needs to improve as these assessments are required to help with creating care plans. Intermediate care is not provided at Woolnough House. Woolnough House DS0000034896.V333778.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 People who use this service experience adequate quality outcomes in this area. People’s personal, social and healthcare needs are well addressed, but they are not underpinned with sufficiently detailed plans of care. There are some shortfalls in medication practices, which could be addressed to make sure that medicines are being given appropriately. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Three care records were looked at. These describe the care and support that people need in order to maintain as independent a life as possible. It was apparent that these documents are being adapted, so that they become more person centred to identify how one person differs from the next. One record contained a detailed life history, social history and listed things that were important to that person. For example it described their getting up and going to bed routine, their dietary likes and dislikes, and the types of television programmes they liked to watch. The other records looked at though did not have this detail. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 12 None of the records clearly identified ‘risk’ and what staff were doing to enable people to lead interesting and fulfilling lives. Whilst one care plan had identified that the person had a poor appetite, poor memory and prone to falling, there were no records to say what the care staff planned to do to help them to remain independent and in reasonable health. An assessment had identified that they were at risk of falling, but no measures were recorded to say how staff planned to minimise the risk of more falls. One person ate their meals very slowly but there was no plan to say how staff would ensure that the person managed to eat enough each day. Although the records were not very detailed people looked well cared for. Four of the seven surveys returned by people said that they always received the care that they need. Similarly five out of the seven returned said that staff always listen and act on what they say. One person spoke highly of their keyworker, who was the one who always helped them with showering. This good practice means a special relationship can develop, whereby staff can get to know individuals really well. There are records of visits from the doctor, district nurse, optician and chiropodist though it might be better if these were recorded on a single document, which would be easier to access and ensure people’s health needs are recorded in a consistent way. One healthcare professional commented that the service provides good care for people who are dying and their families. One person spoken with said the doctor or nurse always saw them in their bedroom, and a visitor said they were always informed if their relative was unwell or had had a fall. The home uses a cassette medication system and the care leaders administer the drugs. The medication record charts were generally completed properly, though the home does not routinely count boxed drugs to check that the projected number agrees with the actual number of tablets. This practice would reassure the manager that drugs are being given and signed for according to the prescription. One person looks after their own drugs. A risk assessment had been completed, but the individual had not signed this. Their signature should be obtained to show their agreement to keeping the drugs securely in their room, in order to protect other people living there. One person was given dissolvable painkilling drugs at lunchtime, which were put in their juice. The staff member left the room though before the drink was all gone so could not check that the person had drunk it all. On the day of the visit this person was not safe to be left to take this drug unsupervised. This was discussed with the manager, who agreed to discuss this with her staff. Controlled drug records were kept correctly, however shortage of storage space meant that the controlled drugs cupboard also contained other medicines. It would be good practice to keep this cupboard solely for controlled drugs. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 13 Care staff were observed speaking kindly and respectfully to people living there. One carer explained that they always checked that it was all right for them to provide personal care for an individual before carrying out the task. They also explained that some people liked to be addressed more informally than others and staff respected their wishes. Woolnough House DS0000034896.V333778.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 People who use this service experience good quality outcomes in this area. People are supported in following their own routine and the meals provided are to a satisfactory standard. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People spoken with said they were generally happy with their lives at Woolnough House. People can choose whether to become involved in social events. Several said they enjoyed their own company, but were always informed about events at the home. A hairdresser visits weekly, although one person has their hair done by their own stylist. A monthly religious service is held at the home and one person said that a member of the Roman Catholic Church calls to see them periodically. The manager is developing a much broader social culture in the home by stressing the need to find out people’s previous interests and hobbies so that where possible these interests can be maintained. For example one person used to go to York races, and the home has organised two visits this year, Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 15 where the person has attended with their keyworker. This is good practice and recognises people as individuals with personal goals and aspirations. Although there is no dedicated activities person the staff have organised events and trips away from the home, such as visits to the railway museum and Bridlington. The local paper and women’s magazines are delivered to the home each week and an activities resource has been established, which includes items in large print, so that they are suitable for many of the people living there. The home also keeps a small ‘shop’ of toiletries and personal items so that people can buy their own things if they choose. Visitors are welcome anytime. One visitor said they were always made to feel welcome and they had “absolutely no concerns” about the home. They also said their relative had enjoyed decorating a terracotta pot, prior to planting it with bulbs. Meals are served in two dining rooms, one on each floor. These are bright and attractively furnished. The meal choice on the day of the visit was chicken casserole or cold ham, with mixed vegetables and creamed potato or jacket potato. There was apple crumble and custard for dessert. Meals are provided as a cook/chill service and are ordered in advance. It would be good practice to have the day’s menu displayed so that people could look forward to a favourite dish. There were mixed views about the meals. Generally people were satisfied with the food, but one person said it was “the worst food ever encountered in my life”. The manager has plans to make changes to the meal provision, so that foods can be adapted in-house to meet the needs of people living there. This is good practice and recognises individual needs and preferences. Two people in their surveys said that they would like more vegetarian options and more spicy food. This was discussed with the manager, who said she would discuss more meal options with people who live there. Fresh fruit is served on an afternoon and people are encouraged and supported to make their own sandwiches at teatime if they choose. This again promotes independence and choice. On the day of the site visit, with staffing levels reduced by two, the staff over the lunchtime period were deployed in such a way, that there weren’t enough staff available to assist with serving the meals and helping individuals. This was discussed with the manager, who agreed that some staff could have been more available at this time. Woolnough House DS0000034896.V333778.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 People who use this service experience good quality outcomes in this area. People and their families can be sure that complaints are taken seriously and staff are alert to any signs of abuse. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People and visitors spoken with said they would feel able to tell someone if they were dissatisfied with anything at the home. However whilst 6 out of 7 people, who completed the surveys, said they knew how to complain, 3 people were uncertain as to whom they should speak with. The manager needs to make sure that all the people at the home would feel able to tell someone if they were dissatisfied. There have been no complaints to the Commission in the last year. The home has received one, which is still ongoing and is being addressed by a more senior manager. There are no records though about this incident in the complaints book. The manager must make sure she obtains all the details for her own records. Both the manager and staff spoken with had an understanding of safeguarding issues and their responsibilities should they see or hear something, which causes them concern. Abuse awareness training is provided when a new employee starts working for the organisation. Although there is no annual Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 17 updating these issues are discussed regularly in staff meetings and supervision. The manager needs to be confident that staff retain this knowledge and awareness so that they can continue to work towards keeping people safe. All staff have a police check completed before they start working for the City of York Local Authority. This makes sure that people employed are not barred from working in the care sector because of a previous offence. This also contributes towards keeping people safe. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience good quality outcomes in this area. People live in a well maintained, comfortable home, which adds to the experience of living there. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: A tour of the home showed it to be generally clean, warm and comfortable. There were no unpleasant smells. One person said in their survey that the cleaning “had gone downhill” recently, though this was not found to be the case on the day of the visit. Equipment and wheelchairs were stored safely although a barrier cream and other pharmaceutical items for personal use were on the windowsills of two toilet areas. This was discussed with the manager, who was disappointed that these had not been moved and said she would speak with staff. There are a number of communal areas, including a small lounge for people who smoke and two dining areas, one on each floor. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 19 Planned refurbishment is going on at the home. All of the bedrooms are being redecorated, and some are also being re-carpeted, with new furnishings and furniture. This has been paid for with a capital grant and will improve the environment for the people living there. Those rooms looked at, whilst not ensuite, are generally of a good size, and many were very attractively presented, with personal effects and furniture. Other improvements have been made to some of the communal areas and the landscaping outside. This has improved the outside space and provided more choice for the people living there. The laundry area is satisfactory and people were generally very happy with the way the home cares for their clothes. The laundry room has a keypad, because of equipment stored there and to keep people living at the home safe. The laundry-person did not lock the door however, when they left the room. This was discussed with the manager because the home needs to make sure people are kept safe at all times. The manager said she would look at a different way of making sure that only approved people could access that area of the home. Staff make sure that appropriate aids are available and used to make sure that people living in the home are protected against infection. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience good quality outcomes in this area. Staff have the knowledge and skills to support the people living there and the recruitment process is satisfactory, thus contributing to protecting people from harm. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: There are five care staff on each early shift, four on the late shift and three through the night. There is also a care leader on each shift. The manager generally is supernumerary. On the day of the site visit these numbers were reduced by two, and this shortfall was particularly noticeable over the lunchtime period. These staffing numbers reduce to four, three and three on the weekend. People spoken with said that the staff were always busy and that this was even more noticeable at the weekend. This was discussed with the manager who was aware of this issue, which had been raised with her managers. New uniforms have been ordered for all staff at the home. Several people had commented to the manager that it was difficult to identify staff roles in the home. New uniforms should help this problem. The manager has also created Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 21 a picture board of all staff, which will help people to know the names of staff working there, as well as providing a talking point. The manager has a training plan, which identifies when staff need update training. She showed in conversation that she recognises the importance of having well-trained staff to enable them to support people appropriately. All the care leaders have a National Vocational Qualification Level 3 in Care and more than 50 of care staff have the award at Level 2. People are more likely to be cared for in a safe consistent manner by people who have a good understanding of their role. Staff spoken with confirmed that they had attended some training this year. The manager has plans to improve carers’ knowledge and understanding. She has arranged for specialist nurses to talk with her staff about common medical problems like diabetes and Parkinson’s disease. This will help staff to have more insight into how these conditions affect the way people live their lives. Two recruitment files were looked at. Whilst references and police checks were completed, neither file contained evidence to prove who they were, nor a health check. Recruitment processes are managed centrally by the Human Resources department of City of York Council. The manager was able to evidence the letter she had written to that department requesting the health check clearance forms. She also needs to be satisfied that people are who they say they are. There is a robust induction process, where new staff have the support and guidance to learn skills and to read the policies and procedures which the home follows, in order to run effectively. There were records, signed by the individual staff member, to show that meetings had been held at specific times to check their progress. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use this service experience good quality outcomes in this area. The home is well run and people’s views are actively sought so that they can influence how the home operates. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The manager has been at the home for just less than a year. She has some experience of running a care home and is currently working towards the National Vocational Qualification 4 Management of Social care award. She is applying to be registered with the Commission. Staff and people spoken with said that the manager was very approachable and was involved in the daily running of the home. She operates an open door Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 23 policy and has a notice displayed in the reception area explaining her availability to visitors. The manager is very enthusiastic and has made a number of changes since starting work at the home. This includes introducing regular residents’ and separate relatives’ meetings, which are minuted. This gives people an opportunity to give their views about how the home runs. She also arranges time when she can sit and talk to people living there so that she can hear their suggestions and grumbles. This gives people the chance to say what matters to them. Residents and relatives have completed questionnaires and blank copies are available for visitors in the reception area. The manager has analysed the results and put forward action plans. She plans to display the results. She should also look at how she can gain the views of professionals who have an interest in the home. A discussion was held about implementing regular care record audits so that the areas lacking in detail can be identified and corrected. This would ensure care plans are complete and appropriate so that people’s care needs can be met. Finance records were checked and found to be in order. People’s money is safely stored for them and receipts are kept for all financial transactions. All the bedrooms contain a drawer, which is lockable, so that people have a secure place for keeping valuables or things that matter to them. Health and safety systems were generally in order and the manager carries out monthly checks. Hot water temperature checks are carried out to reduce the risks of people being scalded by water that is too hot. Random service checks on the hoists and Portable Appliance testing (PAT) were in date. The manager has identified and requested update training in fire safety and moving and handling for several staff members. Fire alarms systems are checked weekly and the fire risk assessment was reviewed earlier this year. Accidents to people living at the home are recorded in their care plans. However in discussion it was noted that one person had attended hospital following a fall. The Commission did not have a record of this incident and the manager was unable to evidence that the home sent in a notification as required under Regulation 37. The home should keep a copy of notifications sent to the Commission to evidence that they are being submitted properly. This was discussed with the manager Woolnough House DS0000034896.V333778.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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? 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(2) Requirement Timescale for action 31/12/07 2. OP7 13(4) 3. OP9 13(2) 4. OP19 13(4) Care planning records must be written in greater detail to reflect people’s different needs and to show how people are supported to stay in charge of their own lives as far as possible. They should be written with the person so they can say what matters to them. All people living at the home 31/12/07 must have an assessment of risk included in their care plan. All identified risks require written records of how the risk is to be managed, in order to keep people safe. Drugs should not be left with 31/10/07 people, unless staff are sure that an individual will take them appropriately and in a timely manner. If the laundry risk assessment 30/11/07 identifies the need for the room to be kept locked then this should be adhered to at all times. Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 26 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 A chronological record of all contacts with external healthcare professionals should be kept in the person’s file. This would demonstrate guidance is being sought and people’s healthcare needs are being met. It would also provide a more consistent approach to meeting needs. It would be good practice for staff to regularly count noncassette drugs. This would check that the actual number of tablets is the same as the expected number and would confirm that drugs are being given and signed for according to their prescription. Any risk assessments, which are carried out to check on a person’s ability to look after their own drugs should include the person’s written agreement to say they will look after their drugs in a responsible way. It would be good practice for the Controlled drug cupboard to contain only those drugs that need to be stored there. 2 OP9 3 OP9 4 OP9 Woolnough House DS0000034896.V333778.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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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