Inspection on 23/05/06 for Woolton Manor

This inspection was carried out on 23rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woolton Manor 24/07/08

Woolton Manor 27/07/07

Woolton Manor 06/12/05

Woolton Manor 06/05/05

Woolton Manor 27/10/04

Woolton Manor 16/06/04

Woolton Manor 12/11/03

Woolton Manor 27/08/03

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

CARE HOMES FOR OLDER PEOPLE Woolton Manor Allerton Road Woolton Liverpool Merseyside L25 7TB Lead Inspector Les Smith Key Unannounced Inspection 23rd May 2006 09:00 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 Manor DS0000025172.V289070.R01.S.doc Version 5.1 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 Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woolton Manor Address Allerton Road Woolton Liverpool Merseyside L25 7TB 0151 421 0801 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) Mr Abid Yousaf Chudary Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66) of places Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 20 Nursing and 46 Personal Care within an overall total of 66 The registered person must ensure that an appropriately qualified person is employed as Manager of the care home. The six places for personal or nursing care must always be accommodated within the Mother Theresa (Nursing) wing. 6th December 2005 Date of last inspection Brief Description of the Service: Woolton Manor is a fine period residence set in its own grounds close to the picturesque village of Woolton, Liverpool. The home offers 66 single bedrooms, with the majority of rooms benefiting from en-suite facilities. For those service users who choose to share, two rooms would be provided with the second room being a sitting room. There are two large lounges; two separate dining rooms, a quiet lounge and a garden/patio area. A separate smoking room is set-aside for clients. Fees at Woolton Manor range from £365 to £470 depending upon the service required. Outside the grounds, all the local village facilities, shops, post office and bus routes are available within easy walking distance. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and was conducted by a regulatory inspector and a specialist pharmacy inspector. A total of 22 hours were devoted to the inspection. The inspectors examined care records and associated documents, staff files, management records and had discussions with staff of all grades, residents and visitors to the home. A full tour of the premises took place in the company of the manager and records such as care plans, staff personnel files and policies and procedures were also examined. A number of staff, relatives and residents were spoken to during the course of this inspection. A total of 20 questionnaires were sent out to relatives and 7 responses were received. A further 4 comment cards were sent to GPs’ who have patients at the home with 3 responses and 7 comment cards to social workers with clients at the home with 0 responses. Responses to questionnaires sent to a random selection of relatives / representatives of residents Yes 1 2 4 10 Have you received a contract Did you have enough information about the home before you moved in Do staff listen and act on what you say Do you know how to make a complaint 6 7 3 6 Always 3 5 6 7 8 9 11 Do you receive the care and support you need Are staff available when you need them Do you receive the medical support you need Are there activities arranged by the home that you can take part in Do you like the meals at the home Do you know who to speak to if you are not happy Is the home fresh and clean 2 2 4 4 1 6 2 1 Usually 3 2 2 2 5 1 3 1 1 Sometimes 2 3 1 1 1 Never No 1 0 Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 6 Responses to questionnaires sent to a random selection of General Practitioners with patients residing at the home Yes 3 3 3 3 2 2 3 3 1 3 2 responses of not asked for 1 response of not known 1 response of mostly No Comment 1 2 3 4 5 6 7 8 9 10 Does the home communicate clearly and work in partnership with you Is there always a senior member of staff to confer with Are you able to see your patients in private Do staff demonstrate a clear understanding of the care needs of service users If you give any specialist advice is this incorporated into the service users plan Is service users medication appropriately managed in the home Do management/staff take appropriate decisions when they can no longer manage the care needs of the service user Have you received any complaints about the home Is the inspection report made available to you on request Are you satisfied with the overall care provided to service users within the home What the service does well: What has improved since the last inspection? There have been many improvements at Woolton Manor since the last inspection. The environment has benefited from a major replacement of carpets, items of furniture and an ongoing redecoration programme. The care planning processes have improved albeit further improvement is still required. The procedures for the receipt, storage, administration and disposal of medications have improved significantly and the concerns expressed at the last inspection have been effectively addressed. The homes management has improved and the new manager has a clear vision of the quality of service that she wants to provide for the residents and their families. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 7 What they could do better: 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. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 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 Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that their needs will be fully assessed prior to accepting a place at the home but cannot be sure that the home has the capacity to meet all of those assessed needs. EVIDENCE: The home’s Statement of Purpose and Service User Guide both lack up to date information in the required elements and both documents are in need of revision. All residents are given a copy of the service user guide and these were seen in some of the rooms. Some relatives spoken to however were not aware of the service user guide and it is recommended that the updated documents be distributed to relatives as well as residents when appropriate. A total of 22 files were examined and only 14 were seen to have a copy of a contract or Statement of Terms and Conditions. There is no mechanism in place to ensure that contracts are received back at the home after being sent out for signature. It is in the best interests of the residents and the home that Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 10 appropriate contracts or Statements of Terms and Conditions are maintained in good order and both parties hold copies. Pre-admission assessments were seen to be present in all care files examined. However the detail documented was not always sufficient in quantity or quality to construct an initial care plan. This has primarily been due to the inappropriate documentation that was being used and the manager demonstrated a new pre-admission assessment document that has been sourced which will provide the necessary information in future. Woolton Manor cares for residents with a wide range of dependency including strokes, diabetes and memory loss. There is a full range of aids and equipment such as assisted baths, shower rooms, hoists and slings and a lift available to promote independence. A lack of specialist training for staff in specialist areas such as e.g. Diabetes and Tissue Viability means that it is not possible for the home to demonstrate the capacity to care for residents with specialist problems particularly for residents with nursing needs. Prospective residents and their families or representatives are positively encouraged to visit the home at any time for as long and as often as they wish before making a decision as to whether they wish to accept a place at the home. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning and medication management processes have improved but still fall short of the standard required to promote the health, welfare and safety of residents. Residents privacy and dignity are respected at all times EVIDENCE: A range of care plans and associated documentation were examined on the day of inspection. These included residents with differing needs such as sensory impairment, specialist nursing needs and varying levels of cognitive ability. The care planning process was found to be neither comprehensive nor consistent in either of the two wings (nursing and residential) of the home. Care plans were seen to be present in the care files examined and included plans for all identified problems in relation to the activities of daily living but it is a concern that care plans were not always present for more complex and specialised needs. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 12 The standard of regular care plan review was variable ranging from a detailed evaluation of care to an inadequate statement such as ‘no change to care plan’ with no justification as to why the care plan was to continue. The regular evaluation of care plans is essential to monitor the effectiveness of the care delivered and therefore the evaluation must detail the effectiveness or otherwise of care delivered thereby justifying any changes or no change to the plan. The standard of care plan reviews was better on the residential wing than the nursing wing. Daily report sheets were completed in variable amounts of detail on both wings. Some members of staff record a good level of detail whilst others record non-specific comments such as “settled and slept well”, “satisfactory morning”, appears bright”, and “no change”. Statements such as these give no indication as to the actual care delivered, the outcome of that care or how the resident has spent their day. The promotion of independence invariably involves an element of risk, which is managed via the completion of relevant risk assessments. The required risk assessments were lacking in most of the care files examined. Where risk assessments were present and reviewed, examination showed that the reviews did not always reflect changes, which were evidenced in other parts of the care file thereby making the risk assessments inaccurate. It is essential that risk assessments are completed accurately and reviewed at appropriate intervals in order to promote the health and safety of the residents. Wound management if required on the residential wing is managed by the District Nursing service and evidence was seen that there is a good relationship with the service with wounds being referred and seen promptly. Examination of wound management records in the nursing wing showed that information was variable ranging from no record to comprehensive wound mapping with size, exudate and dressing type providing a good detailed record. Full mapping of all sores or wounds must be undertaken to ensure that improvements and deteriorations can be identified in the early stages to further plan the treatment to be given. Residents identified as having sensory impairment had no plans in place to address their special needs and plans in relation to their activities of daily living failed to reflect the additional input and care required due to their sensory impairment. Documentation in several care files showed that where concerns in relation to aspects of care had been identified e.g. loss of weight, appropriate referrals had been made for specialist advice from the multi-disciplinary team e.g. dietician. Associated care documentation such as fluid charts and regular monthly observations are an integral part of evaluation of care. A nutritional care plan Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 13 can only be judged to be effective if there is a recorded weight gain or demonstration of weight stability. In many of the care files these observations were poorly recorded with some not having been done for three months. The variable standard of care planning is a cause for concern given that the poorest standards were observed on the nursing wing where care plans are constructed and maintained by trained staff and it is in these areas were residents have the more complex needs. The responses to the questionnaire show that 71 thought that the care and support they needed was only usually or sometimes received and this is almost certanly a result of the inconsistency in care planning. A pharmacy inspector inspected medication management and her report is available as a separate document but the requirements in relation to medication are included in this report. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. As far as possible residents have choice and flexibility in how they spend their day in the home, and participate in leisure activities according to their choice and preferences thereby promoting independence and individuality for each resident. Meals at Woolton Manor are good, offering choice and variety whilst catering for residents dietary needs or cultural preferences EVIDENCE: The activities co-ordinator is employed for 18 hrs per week over three days and this severely limits the number and nature of activities offfered. The current activities person is about to leave for personal reasons and there is now an opportunity for the home to consider recruiting a full-time co-ordinator which would be more appropriate for the size of the home. The activities currently provided rotate through a four weeek cycle and apart from pampering sessions mainly for the ladies, all activities are group based. The home shows feature length films on a regular basis and one relative commented that they are not always suitable for the residents citing a recent showing of ‘Phanthom of the Opera’. Two local churches make regular visits to the home, one weekly and one monthly. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 15 The activities provided should be reviewed to reflect the needs and capabilities of the current residents and also provide more one to one activities and social interactions for those residents who for whatever reason do not participate in the group activities. It is recommended that participation in activities be recorded in individual care files. This would allow for profiles of likes and dislikes to be established thereby allowing activities to be tailored to meet needs and preferences of individual residents. Visitors are welcome at the home at any time and evidence of this was seen with visitors arriving at the home from early morning. The opportunity for making decisions and exercising choice in many aspects of daily life is limited for those residents assessed as having impaired cognitive ability but staff are encouraged to promote choice wherever possible e.g. choosing a set of clothes for the day. Residents who are less dependent are able to choose how they wish to spend their day and it was observed that residents came and went from the home as they pleased when they were able to do so. Residents spoken to confirmed that they had as much choice as they wished. Comments included I go out most days, I do what I want to do but it is nice to have the opportunity if I want. Residents said that they enjoy the food at Woolton Manor with comments such as ‘food very good’, ‘food is good’ and waste was observed to be minimal. However two residents relatives commented that the food took too long to be served at meal times. A cooked breakfast is always available and the main meal of the day is served at teatime except on Sundays when a traditional roast lunch is served at midday and a finger buffet is provided at teatime. Although there is no choice of main meal on the menu, a range of alternatives is always available, including baked potatoes, sandwiches, soup and hot snacks. The menus show that in addition to the main meals cheese and biscuits or fresh fruit are always available as alternative choices for the desert at any meal. Residents choose their meal the day before and the chef said that he tries to meet requests that are not on the menu or the usual alternatives. For instance, on the day of the inspection one resident was having poached egg on toast instead of the set meal or one of the usual alternatives. Lunch is also often a substantial cooked meal. The chef caters for special diets and these were displayed on a whiteboard in the kitchen. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their families may be certain that complaints are taken seriously and will be acted upon in a timely and effective manner and those residents are protected from any form of abuse. EVIDENCE: There have been no complaints to the home or to CSCI since the last report. This is a significant improvement and reflects the proactive approach taken by the home management since the appointment of the new manager. It is strongly recommended that a complaints register be established and that verbal complaints and actions taken are documented in order to demonstrate an open and transparent process. All residents are registered on the electoral roll and assistance is provided were necessary to allow residents to exercise their rights whenever they wish. Examination of training records showed that only 37 of staff have received training in abuse, the various forms of abuse and their recognition. Four members of staff on duty were interviewed and only two were able to demonstrate knowledge of abuse and the procedures to follow if abuse was suspected and the protection of the vulnerable adult processes. Training in Protection of the Vulnerable Adult needs to be completed for all staff. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment at Woolton Manor is good providing a homely and comfortable place to live. EVIDENCE: A major redecorating and refurbishment programme is in progress with new items of furniture and carpets making for a substantial improvement in the environment. All of the residents’ rooms are spacious and bright and recent redecoration of some was clearly evident. A tour of the home was carried out accompanied by the manager. The small kitchen area in the residential wing dining room is in poor condition and needs refurbishment. The inspector was informed that work would be undertaken to address this in the very near future. The carpet in the nursing wing lounge that has not been replaced needs deep cleaning due to heavy staining in several areas. One room contained a fridge belonging to a resident that was not used Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 18 and in poor condition. There is a need to discuss with the resident or relative concerned and arrange for either repair and cleaning or disposal. An effective maintenance programme was evidenced by the lack of minor faults such as extractor fans not working which was a concern on the previous inspection. Communal areas are spacious, bright and new carpets throughout the corridors and two lounges add to the sense of a comfortable and safe environment. Specialised equipment such as a lift, assisted bath and shower rooms, hoists and appropriate relevant toilet aids required to assist residents to maximise their independence is clearly evident throughout the home. Many of the residents have personalised their rooms with their own pictures, furniture, entertainment equipment and other memorabilia, a process facilitated by the generous size of the rooms and encouraged by the homes management. Cleanliness was seen to be variable in different areas of the home. The questionnaire responses confirm this with 29 saying the home was clean and fresh sometimes or never and 43 saying it was usually clean and fresh. Woolton Manor is a large period building and due to its size and physical layout requires substantial input to maintain the required standard of cleanliness. There are currently 118 contracted hours for cleaning and it is recommended that consideration be given to reviewing this figure. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are sufficient staff employed to meet the assessed needs of the residents and recruitment policies but recruitment policies are not always robust enough to promote the protection and safety of residents. Staff training is poor and fails to provide the competency necessary to promote the safety of all residents. EVIDENCE: The residential unit is staffed in the day by a senior carer or Residential Care Manager and at least five care staff; a registered nurse staffs the nursing unit with six care staff in the morning and five after 1400 hrs. However 43 of questionnaire respondents said that staff were only sometimes available when needed and two relatives spoken to both commented ‘it takes too long to answer the call bell’. The home also employs catering staff, a part-time administrator, an activities organiser, domestic staff and a handyperson. At night there is always an RGN on waking night duty, plus care staff. A random selection of staff files were examined and revealed that the homes policies and procedures were not always being complied with and consequently do not meet the required standards. The findings are as follows: One member of staff commenced before Pova First check received One member of staff had no references One member of staff had only one reference Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 20 One member of staff had no contract Second reference for one member of staff not received until 6 weeks after commencement of duty Four files had no job description All staff files had completed inductions The administrative officer has compiled new, comprehensive, well-organised files for all staff but this process needs to include an audit of items within the files and action taken to obtain the missing items. Staff may not be employed under any circumstances if they do not have clearance against the POVA (protection of Vulnerable Adults) register and then only under supervision until the full CRB check is received. Induction training is in place and the home has obtained and started to use a commercially produced induction and foundation-training programme. Examination of the training records showed that nine of the 29 care staff have NVQ2 and two having NVQ3. This equates to 38 , which is substantially short of the 50 target by 2005. The Registered Person should seek to extend the NVQ training programme to achieve the minimum standard of 50 for care staff and facilitate NVQ qualifications for ancillary staff. A total of thirteen staff is shown as being qualified first aiders but all the qualifications were for one year and are now invalid. Consequently there are no qualified first aiders at the home. The numbers of staff with other valid qualifications are: Moving and Handling Health & Safety Food Hygiene Fire Training Pova 54 18 28 (Only 2 of the five catering staff) 48 37 There is a clear urgent need to address the training of staff particularly in relation to the mandatory training requirements. The lack of training in specialist areas such as caring for the older person with dementia, challenging behaviour, diabetes has been highlighted in a previous section of this report and also needs to be addressed as soon as possible. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new manager is able to provide the leadership, guidance and direction to staff that ensures residents receive consistency of care and are safe in the home. Woolton Manor does not have a comprehensive quality assurance process; this results in some practices that do not promote the health, safety and welfare of the people using the service. EVIDENCE: The home’s new manager took up her post on 9th January 2006 and is currently being considered for registration by the Commission for Social Care Inspection. She has support from the Deputy Manager (a registered nurse) and the Residential Care Manager, who has an NVQ Care 2 & 3, NVQ Level 4 Registered Manager (Adults) and Operational Management Level 5. Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 22 The new manager has made significant improvements at the home and the morale of staff at the home has improved as evidenced in discussions with individual staff members. Whilst There has been no progress on the development of a quality assurance system since the last inspection and this must be addressed as soon as practicable. Regular staff meetings are held for both day and night staff. Relatives meetings are also held on a regular basis the last one being in April 2006. It is a measure of the managers’ commitment to promote the residents welfare and interests that following a suggestion at the April meeting the next one is being held at the weekend on a Sunday to enable more people to attend and contribute. The registered person makes regular visits and reports are submitted to the CSCI. Staff supervision is now being carried out and is ongoing Records are safely and securely stored in the two offices in the home. The home has full time administrative staff who are responsible for ensuring that records are up to date, accessible and securely stored in accordance with the Data Protection Act. Personal resident monies and personal allowances are managed by the either the residents or their representatives. Fire safety checks are carried out regularly and recorded and a fire risk assessment was seen. Relevant maintenance contracts, checks and safety certificates were seen for: Fire alarm and nurse call system Portable Appliance checks Electrical installation Emergency lighting system Legionella checks Gas safety certificate Passenger lift Assisted baths Hoists All certificates seen were in date and valid Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 23 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 2 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 3 3 Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 24 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 OP1 Regulation 4 Requirement The registered person must ensure that the statement of Purpose is updated to reflect up to date information and contains all of the required elements as detailed in schedule 1 of the Care Homes Regulations 2001 The registered person must ensure that the Service Users Guide is updated to reflect up to date information as detailed in regulation 5(1)(a to f) of the Care Homes regulations 2001 The registered person must ensure that all service users receive a copy of the Terms and Conditions or a contract if self funding The registered person shall ensure that the care home is conducted so as: (a) to promote and make proper provision for the health and welfare of service users to make proper provision for the care Version 5.1 Page 25 Timescale for action 31/07/06 2 OP1 5 31/07/06 3 OP2 5(3) 31/07/06 4 OP4 12 & 18 31/08/06 (b) Woolton Manor DS0000025172.V289070.R01.S.doc and, where appropriate, treatment, education and supervision of service users (Refer to risk assessments, wound records, dementia and special needs e.g. sensory impairment) 5 OP7 15 The registered person must ensure that care plans are relevant, up to date and completed in an accurate and appropriate way POLICIES: The registered person must ensure that medication policies and procedures be reviewed in line with Royal Pharmaceutical Society of Great Britain and Nursing & Midwifery Council guidelines to cover all aspects of medicines management, particularly the administration of medication via PEG tube. (Previous timescale of 28/02/06 not met) 7 OP9 13(2) Sch 3 (i) The registered person must ensure that the receipt, administration and disposal of Controlled Drugs is recorded in a Controlled Drug register. A designated, trained member of staff must witness the administration of Controlled Drugs. (Previous requirement not fully met) 8 OP9 13(2) Sch 3 (i) ADMINISTRATION: The registered person must ensure that all medication is only administered in accordance with the General Practitioners instructions. There must be a full record of all medication currently 25/05/06 25/05/06 31/07/06 6 OP9 13(2) 31/07/06 Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 26 prescribed for each resident. Previous timescale of 14/02/06 not met) 8 OP12 16(2)(n) The registered person shall having regard to the size of the home and the number and needs of service users consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. 31/08/06 9 OP18 13(6) The registered person shall make 31/07/06 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse The registered person must make suitable arrangements for maintaining satisfactory standards of hygiene in the care home The registered person must ensure that the NVQ training programme is extended to include all staff at the home and appropriately facilitated The registered person must obtain all the documents and records for all persons employed as specified in Schedule 2 of Regulation 19 of The Care Homes Regulations 2001. The registered person must ensure that all staff required to work at the care home receive (i) training appropriate to the work they are to perform; and (ii) suitable assistance, DS0000025172.V289070.R01.S.doc 10 OP26 0616(2)(j) 31/07/06 11 OP28 18 30/09/06 12 OP29 12, 19 30/09/06 13 OP30 18(1)(c) 30/09/06 Woolton Manor Version 5.1 Page 27 including time off, for the purpose of obtaining further qualifications appropriate to that work 15 OP33 24 The registered person must 30/09/06 ensure that an effective quality assurance and quality monitoring systems are put in place. 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 OP2 Good Practice Recommendations It is recommended that a mechanism be put in place to ensure that signed copies of contracts sent out are returned and filed appropriately It is recommended that participation in social and recreational activities be included on the individual daily report records in order to give a comprehensive picture of how a resident spends their day. It is strongly recommended that criteria for the administration of when required and variable dose medication should be clearly defined and recorded for all service users prescribed such items. Written authorisation should be obtained from the prescriber whenever medication is administered outside the product licence e.g. via PEG tubes. 4 OP16 It is strongly recommended that a complaints register be established and that all verbal complaints of whatever level of seriousness and actions taken be documented. 2 OP12 3 OP9 Woolton Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 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 Manor DS0000025172.V289070.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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