Inspection on 20/06/08 for Woolton Grange Care Home

This inspection was carried out on 20th June 2008.

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

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

Woolton Grange Care Home 26/06/07

Woolton Grange Care Home 27/06/06

Woolton Grange Care Home 31/01/06

Woolton Grange Care Home 22/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Woolton Grange Care Home Woolton Grange Care Home High Street Woolton Liverpool Merseyside L25 7TE Lead Inspector Mr Paul Kenyon and Stephanie West Unannounced Inspection 20th June 2008 09:30 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 Woolton Grange Care Home DS0000064524.V366319.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. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woolton Grange Care Home Address Woolton Grange Care Home High Street Woolton Liverpool Merseyside L25 7TE 0151 428 9861 0151 428 1118 paul.ashmore33@hotmail.com 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) Hill Care Limited Mrs Samantha Yeardon (Acting) Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 43 beds (OP) providing personal care. 26th June 2007 (Key Inspection) 22nd February 2008 (Random Inspection) Date of last inspection Brief Description of the Service: Woolton Grange is in the suburbs of south Liverpool, close to the local shops and other community facilities in Woolton Village. Bus routes to Liverpool city centre and other parts of the city pass nearby. The home is registered to accommodate up to 43 older people and provide them with personal care. It does not provide nursing care. Up to eight people attend Woolton Grange for day care. It costs between £322 and £432.15 per week to live there. Woolton Grange is a distinctive, renovated former church building and has both single and double bedrooms. There is range of communal spaces including a large conservatory and a smoking room. The home has parking space to the rear and residents have access to the different levels of the home via lifts. Woolton Grange Care Home DS0000064524.V366319.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 two stars. This means the people who use this service experience good quality outcomes. This was the main key inspection for this service this inspection year (April 2008 to March 2009) and was unannounced. A Pharmacy Inspector whose role was to assess the management of medication within the service accompanied the Lead Inspector. National Minimum Standards for older people were used to measure the quality of care that Woolton Grange provides. The inspection took place during the morning and afternoon and included a tour of the building, interviews with those who use the service, examination of records relating to the care provided, interviews with staff and observation of the provision of lunch. The views of those who use the service and staff are included later in this report. In addition to this, surveys were made available to those who use the service, staff and relatives. These surveys are yet to be returned at the time of writing this report yet those returned will be used as evidence for the ongoing regulation of the service. What the service does well: The service is good at outlining all the needs of individuals into a plan of care, which in turn is reviewed, on a regular basis. The health needs of those who use the service are met ensuring their wellbeing. The service is good at striving to promote the privacy and dignity of those who use the service ensuring their rights are respected. The service is good at ensuring that individuals are able to pursue their daily routines and maintaining contact with family and friends. The service is good at maintaining the independence of individuals as much as possible. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 6 The nutritional needs of individuals are met although recommendations are made in respect of the assistance provided to individuals with eating and in promoting independence. Those who use the service and their families are provided with the information they need to make a complaint and are protected from abuse through training and the policies and procedures of the service. Those who live at Woolton Grange live in an environment, which is steadily being refurbished. Trained and qualified staff sufficient in number to meet their needs supports those who use the service. Those who use the service are protected by the service’s recruitment process. Those who live at Woolton Grange benefit from receiving a service that is managed by an individual who has sought to improve communication between the staff team and relatives. The views of those who use the service and relatives are obtained in a transparent manner so that all are consulted on the standard of care provided. The financial interests of all are safeguarded to ensure that they have access to the monies they are entitled to. Comments from staff and those who use the service included: ‘Staff are very nice and very polite ‘If I want privacy I can go to my room’ ‘If I had a complaint I would tell the ‘head’ ‘The food is alright’ ‘I am keeping well in my health and have not needed to see the Doctor’ ‘I am able to see my son’ ‘There is not much to do in the day’ ‘ I get up when I want’ ‘I feel safe’ ‘This place beats the lot’ ‘I am quite happy at the moment, it is alright and peaceful’ I am happy here, it is nice and it is kept clean, I like the company and the food is nice’ ‘I have been here six weeks, I have settled in, lunch was very good-I am keeping well and have not needed to see the doctor’ ‘I have worked here seven years and I enjoy it’ ‘I have got first aid, food hygiene and health and safety’ Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 7 ‘I have received protection of vulnerable adults training and know about whistle blowing, the manager is really supportive’ ‘We have got enough staff although sometimes there is sickness, the best thing about being here is the residents and staff but when there is sickness there needs to be consistency’ ‘I am doing my NVQ Level 4’ ‘Get support from the manager, there is enough staff but we have had sickness, I like the teamwork between the staff and I think I need training in issues such as diabetes and dementia’ ‘ I think that things have improved with the new manager, the building is gradually being refurbished, I like the flexibility and chance to use skills in the home and can use my initiative. I can’t think of anything that needs improving. What has improved since the last inspection? What they could do better: The service must ensure that those who come to live at Woolton Grange are assessed prior to their admission so that their needs can be identified and met. The service must ensure that all aspects of the management of medication are safe. The service must ensure that wheelchairs are checked to ensure the safety of individuals. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 8 A number of good practice recommendations are also raised in this report. 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. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 9 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 Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 10 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): Standard3. Standard 6 is not applicable to Woolton Grange at present. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who come to live at Woolton Grange do not always benefit from having their needs identified prior to them being admitted. EVIDENCE: Assessment information was examined for five individuals. Two of these individuals are privately funded and in both cases, the service had assessed their needs prior to them coming to live at Woolton Grange. The service’s own assessment refers to health and social needs as well as the level of support required in relation to nutrition, manual handling, the risks of falls, pressure sore care, the level of dependency needed and assistance with promoting continence. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 11 A Local Authority funds the other three individuals. In all these cases, the service had conducted a review prior to them coming to the service and in two cases, Local Authority assessments had been gained prior to their admission. In one case, no Local Authority assessment could be evidenced. This is raised as a requirement in this report. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service have their needs identified in a plan of care that is reviewed on a regular basis and enables the needs of individuals to be met. EVIDENCE: Care plans were examined for five individuals who had come to live at Woolton Grange since the last inspection in 2007. All care plans examined noted that there were needs outlined which were unique to the individuals concerned. These included details of the needs and the action required to address them by the staff team. Specific needs related to sexuality, privacy, mobility, personal hygiene, communication, psychological well-being, oral hygiene, outings, safety, routines and diet. All care plans had been reviewed on a monthly basis since they had been devised. The Manager is seeking to introduce the opportunity for relatives to confirm the content of care plans and this has been Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 13 relayed to all relatives. This was evidenced as a proposal within the intended newsletter for July 2008. All care plans are accompanied by daily reports and all plans are securely kept in the main office and locked away when not in use. Health records for five people were examined. There was evidence that all are registered with a General Practitioner. Records examined related to weight. All had been weighed on a monthly basis and weekly in some cases depending on their nutritional assessment. When needed, individuals had been referred to a dietician and this was evidenced in health records. Initial assessments did not provide the weight of individuals on admission. This is raised as a recommendation in this report to enable future progress of a person’s weight to be measured. A dependency assessment is in place for each person, which enables a view of the support they need to be provided. Four individuals had been assessed as being of low dependency with one being of medium dependency. Nutritional assessments are in place for all and these are reviewed on a monthly basis. Continence assessments have also been completed and again are reviewed monthly. Care plans relate to health needs such as oral hygiene. Pressure sore assessments are in place for all individuals and again these are reviewed monthly. Records are maintained in respect of any medical appointments that people may need. These ranged from influenza vaccinations, hospital admissions, dietician visits and doctor appointments. There was evidence for all that optician’s prescriptions had been obtained. Interviews with individuals confirmed that they were well but have had to see the Doctor on occasions when not well. A comment from person stated: ‘I have not seen a doctor because I am feeling alright at the moment and don’t need to’ We observed part of the morning medicines round. Medicines were administered with care, by trained staff. We saw that medicines were given at the correct time of day and care was taken to ensure any special instructions such as ‘before food’ were followed. Where people choose to administer their own medicines assessments have been completed, to help ensure people receive any help they may need to do so safely. Consideration was being given to people’s medicines when they where away from the home. Advice was being sought from the community pharmacist to try and ensure suitable arrangements were made to meet people’s needs whilst away. The service had put protocols in place for giving ‘when required” medicines’ such as painkillers and sedatives to make sure people received them in the right dosage, and only when they were needed. But, some of these could be Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 14 expanded to provide clearer guidance to staff about when theses medicines may be needed. The home had arrangements in place so that non-prescribed medicines for the treatment of minor ailments could be given. This benefits residents as they can receive treatment for conditions such as minor pain without delay and without the need to see the doctor. But, it was of concern that there was inconsistency in the way the administration of these medicines was recorded. To ensure homely remedies are safely administered they should only be used in-line with a written policy describing their correct use. Records were good for the receipt of medicines into the home and for the safe disposal of unwanted medicines. We looked at the medicines stock and records and found, with the exception of a rare discrepancy, these ‘added up’, showing medicines had been given correctly. Regular audits (checks) are carried out to make sure that medicines are handled in accordance with procedures. Records of communications with, and advice from, health care professionals such as doctors were mostly good. But, it was of concern that dose changes were not always well managed. We saw that there were sometimes delays in carrying out new instructions from the doctor; this could affect people’s health and well-being. Particular care is needed when administering Warfarin, as the dose may change after checks at a Warfarin clinic. Records showed that the correct dose had not always been given. Staff explained that there had been problems because the booklet with the new instruction had been going to the wrong address. It is important that the dose of Warfarin is always confirmed with the clinic to ensure this medicine is given correctly. Controlled drugs handling was mostly clearly recorded in a proper register but a pack of injections for use by a district nurse had not been entered in the register. All controlled drugs that the home keeps need to be shown in the register to enable them to be accounted for. A shared room was viewed. Screening was available to ensure a degree of privacy between those who share the room. Preferred terms of address are included within care plans as well as reference to their religion. Relatives had commented in March 2008 about the laundry systems of clothing going missing as well as people wearing other clothing. The service indicated the action it would take to address these issues in the result s of this service. Clothes were noted to be discreetly marked yet the storage of laundered clothing in the laundry is not consistent. Some clothes are stored in boxes while others are included on shelves and this leads to a potential for clothes being mixed up between individuals or going missing. It is raised as a recommendation that a consistent system for the sorting of laundered clothes is adopted by the home. Evidence was available throughout the inspection of staff maintaining the dignity of individuals in toileting and other personal Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 15 hygiene tasks as well as knocking on doors before they entered bedrooms. Those who use the service were asked if they wished to speak with the Inspector. There was evidence that mail sent to the service for individuals had been left unopened. There was evidence throughout the visit of staff interacting with those who use the service in a dignified and respectful manner. Comments from those who use the service in interviews included: ‘I get my privacy’ ‘Staff are very good and polite’ ‘They are never rude’ Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 16 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): Standards 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of those who use the service are respected and steps should be made to introduce the new activity programme as soon as possible. Those who use the service are able to maintain contact with their relatives so that they are not isolated. The independence of individuals in maintained as far as possible. The nutritional needs of individuals are met although steps should be taken to ensure that mealtimes are an event for these individuals and not a process. EVIDENCE: Two were people asked about their routines in the home. They both felt that they could get up when they wanted or retire. Observations were made confirming that individuals were free to pursue their own activities and were able to do this in private. An activities programme has been updated yet has Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 17 not been made available or put on display. It is recommended that this be done. One individual stated that there was not much to do in the day. Surveys sent to relatives by the service were returned and some considered that they had been unaware of an activities programme when their views were canvassed in March 2008. The service is seeking to employ an activities coordinator. Preferred activities are recorded and those who do not wish to participate have their wishes respected. Some care plans noted that while individuals did not wish to join in activities, consideration was made to the possibilities of social isolation. The service has its own transport for activities. There was evidence through the visitors’ book that individuals receive visitors. Observation noted that individuals are able to receive visitors in private either in their bedrooms or in the garden. Plans are in place evidencing a move by the manager to improve communication between the management team and relatives following comments in the relatives’ surveys completed in March 2008. The production of a bi monthly newsletter has started as well as the proposed formation of a relative’s forum connected with the service. There is also evidence that the manager has extended an invitation through a written notice in the week for relatives to speak with her if there are any issues about the care provided. Observation through the inspection noted those individuals who are able to mobilise independently doing so. There was also evidence that the service does not become involved with all the finances of individuals but only stores monies for four individuals. Financial records are maintained. Advocacy services are not used at present but are available if needed. There was evidence of personal items being introduced in individuals’ bedrooms and this was noted during a tour of the building. No inventories of personal possessions are maintained with the result that in cases where personal items go missing, there is no evidence that these are accounted for. This is raised as a recommendation in this report. Lunchtime was observed during the inspection and focussed on the assistance provided to those who require assistance with feeding. This involved three people. Staff interaction with these individuals during this time seemed minimal with the result that an opportunity to communicate with individuals on an individual level and non-verbally appeared to be missed. It is recommended that training be provided to staff in respect of the interactions with those who require feeding. The lunch was provided in a dignified manner but communication from staff was minimal and could be improved. The impression was that this meal was a process not an event for those who use the service. Other individuals who are able to feed themselves were enabled to do so. There was evidence that where individuals were not able to attend lunch for whatever reason, that they could have lunch later than others and this was observed. Another individual was feeding herself using a bowl. It is recommended that more appropriate plate aids such as adapted cutlery and plate guard be introduced to ensure consistency in the presentation of meals. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 18 The Kitchen is well equipped and dietary information is available for the chef. The chef is new to the service and there was evidence available that the menus are being reviewed and updated. A menu is on display in the dining area with evidence of alternatives if required. The dining area is a large facility able to cater for all, although one person noted to be having lunch in their own room. Care plans make reference to the dietary needs of individuals although there was no one in the sample taken who had a special diet as such. Nutritional assessments had been completed and reviewed monthly with input from dieticians where appropriate Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information on how to make a complaint is available to those who use the service and their relatives so that any issues can be acted upon. Those who use the service are protected from abuse. EVIDENCE: A complaint procedure is in place and this contains details of the Commission for Social Care Inspection although the contact details are out of date and it is recommended that these be updated. The views of relatives in respect of the complaint procedure have been obtained. Complaints records are maintained. One complaint has been received by the Commission for Social Care Inspection and the service since the last inspection. This complaint is ongoing at the time of this report. Interviews with those who use the service stated that they would approach staff if they had a complaint. No allegations of abuse have been reported since the last inspection. A Local Authority procedure on safeguarding adults is in place for reference as well as the service’s own procedure. Interviews with staff noted that they had received protection of vulnerable adults training and were aware of the whistle blowing procedure. Information is in place in respect of dealing with acts of physical or Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 20 verbal aggression as well as staff’s involvement in the financial affairs of those who use the service. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Those who use the service benefit from living in a well-maintained environment but do not benefit from living in a completely hygienic environment. EVIDENCE: A tour of the exterior of the building noted that some window frames require replacing or redecorating. It was confirmed that this work had been identified through the refurbishment plan made available during the inspection. The refurbishment plan for 2008 includes replacement of bed soft furnishings, redecoration of bedrooms, replacement of carpets, tidy exterior, replacement Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 22 of the wheelchair lift, redecoration of corridors. Maintenance staff are employed in the home and a system for reporting any ongoing repairs is in place as evidenced through records. The maintenance staff was able to confirm to the inspector of ongoing tasks. The home is accessible for those with limited mobility and security is maintained with the provision of a coded lock in place on the front door. Grounds are accessible to those who use the service with seating available to the front, which in turn is not overlooked and was being used during the visit. No Close Circuit Television systems are in place. The grounds receive sunlight and are well maintained. Some minor decorative issues were noted internally yet these are to be addressed through the refurbishment programme. The tour of the building also noted some offensive odours present in one corridor area and part of the lounge although these are not widespread throughout the home. It is required that steps are taken to eradicate this odour in the affected areas. It is understood that the source of the odour has been identified. It was noted that there was a stale odour in the sitting room area near to a seating the seats. The Laundry is separate from areas of food preparation and storage. An impermeable floor is in place as well as hand wash facilities available. Washing machines and driers are available as well as a sluicing facility, which is separate from toilets used by those who use the service. Protective clothing is available for staff and observed to be used during the visit. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A qualified and trained staff team who are sufficient in numbers to meet their needs and whose recruitment protects them supports those who use the service. EVIDENCE: A staff rota is in place, which indicates the designation of staff as well as the presence of ancillary staff such as caterers and domestic staff. A Management structure in place as well as day and night time care assistants. Dependency levels of service users are monitored on a monthly basis through a dependency form. The Staff rota during the day of the visit indicated the following staff on duty: 1x Manager, 1x Deputy Manager, 5x Care Assistants, 2x Kitchen staff, 4x Domestic staff and 1x Maintenance staff. Information received in the Annual Quality Assurance Assessment submitted prior to the inspection suggests that over 50 of staff have attained at least National Vocational Qualification Level 2. Interviews with three members of staff noted that one had attained NVQ Level 2 and 3 and was commencing Level 4. Another had signed up for Level 2. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 24 Personnel records examined for three members of staff. All complied with regulations and included references, checks with regard to criminal records checks, interview records and health declaration as well as confirmation of their identity. Notices for forthcoming training are on display in the staff room. Interviews with staff confirmed the following training had been received: first aid, food hygiene, health and safety, protection of vulnerable adults training, manual handling. All training was evidenced on files. Inductions were also included within personnel files for new starters. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a management structure and an individual who is seeking registration with the Commission for Social Care Inspection. Relatives and individuals have the opportunity to comment on the quality of care provided by the service. The health and safety of those who use the service is not fully promoted. The financial interests of those who use the service are safeguarded. EVIDENCE: Since the last inspection, the Registered Manager has left the service. There is an Acting Manager who is yet to submit an application to Commission for Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 26 Social Care Inspection. This inspection noted that the manager had sought to provide time for relatives to meet with her, the introduction of a newsletter, and the proposed formation of a relatives group and the continued use of surveys for relatives in the performance of the service. Staff interviews asked about the conduct of the Acting Manager: comments included: ‘She is really supportive’, ‘she provides support’, ‘I am allowed to use my initiative’ ‘Things have improved’ Quality assurance surveys from the service have been sent to relatives in March 2008. Results of this are on display and include positive comments including those areas were improvement is needed. In addition to this, where negative comments exist, a statement of intent in how the service will improve these areas have been outlined-it is recommended that surveys are sent out again before October 2008 to see that where shortcomings have occurred-they have been addressed and where good practice has been identified that this continues. The Inspector was able to see all records and able to speak with those who use the service and staff in private. Requirements from the last key inspection had been met. The majority of those who use the service either deal with their own finances or rely on families. The service only provides a storage place for monies for five people and this only involves giving monies out to those on request. Records are maintained and are accountable. All monies are securely stored. Training records and interviews with staff confirmed that they had received mandatory training in manual handling, first aid, infection control, and food hygiene and fire awareness. Planned training is imminent with further staff to receive mandatory training updates. Accidents are recorded with an analysis of accidents completed on a monthly basis. Tests to fire alarms are conducted weekly and emergency lighting is tested monthly. Evidence is in place of fire drills and servicing to fire fighting appliances. Water temperatures are monitored and radiators are covered. Electric certificates are in place as well as gas certificates confirming the safety of such systems A coded lock is located on the front door, which aids security of the building and is released in the event of a fire. Control of Substances Hazardous to Health records are in place and portable appliances have been tested. The operating Organisation has a health and safety procedure document available. General risk assessments are in place relating to the needs of those who use the service (as outlined in Standard 7 of this record as well as assessments in relation to clinical waste, substances hazardous to health, infection control, external activities and the presence of contractors on site. Weekly wheelchair safety checks have not been completed for some time. This is raised as a requirement. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 27 Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 28 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X X X X X X 2 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 2 Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14 Requirement The needs of those who come to live at Woolton Grange must be assessed prior to their admission so that a judgement on how best to meet their needs is made. To help ensure their health and wellbeing, changes to people’s medicines need to be promptly and accurately carried out. The unpleasant odours in a corridor and the lounge should be eliminated to ensure a hygienic and pleasant environment for those who use the service. The health and safety of those who use the service must be promoted through the assessment of the safety of wheelchairs on a regular basis Timescale for action 30/06/08 2. OP9 13(2) 21/07/08 3. OP26 13 21/07/08 4. OP38 23 10/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 30 No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP8 OP10 OP12 OP14 OP15 OP15 OP16 Good Practice Recommendations The weight of individuals should be taken at the point of admission so that progress of their future health can be made. A consistent system for the storage of laundered clothing should be used to ensure the dignity of those who use the service. The new activity programme should be made available to those who use the service as soon as possible to ensure that their recreational needs are met. An inventory of the personal possessions of individuals should be made at the point of admission so that any missing items can be accounted for. Training relating to the skills required to assist individuals with eating should be provided to the staff team to promote the well being of those who use the service. A plate guard and adapted cutlery should be provided where necessary to promote equality for individuals at mealtimes. The contact details of the Commission for Social Care Inspection should be updated in the complaints procedure so that individuals and their families have complete details of the process for making complaints Surveys in respect of the quality of care provided should be made available to relatives and those who use the service by October 2008 to ensure that progress made in respect of relatives’ comments can be determined. 8. OP33 Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Unit 1 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 Woolton Grange Care Home DS0000064524.V366319.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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