Care Home: Woden Resource Centre

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What the care home does well The service is effectively managed. The manager is supported by Team Leaders who have well defined designated roles and responsibilities providing a good quality service to the people accommodated. Staff have a good understanding of the individual needs of the people using the service, which given the number of people accessing the service throughout the year it is a credit to the staff and managers. The self-assessment completed by the manager and sent to CSCI was detailed and acknowledged the strengths, weaknesses and plans for service improvement. Infection control procedures adopted by staff are robust and help to safeguard the numerous people using this service from risk of infection. The centre was found very clean and tidy throughout this unannounced inspection.Record management systems are a credit to staff and managers. All records examined as part of this inspection were easily accessible and presented to an exceptional standard. Views gained during the inspection and compliments the service has received include: "All the staff are very helpful and courteous...its what makes a stay a happy affair". "Carers and staff are excellent" "Woden is like a hotel, it`s beautiful. The staff are so friendly and helpful and the food is delicious...I am so grateful of such a wonderful service" "I would like to express my thanks to all the staff for the courtesy they have shown to me. Bedrooms are very clean, meals have been excellent..." "The standard of service is excellent and everyone always very pleasant". What has improved since the last inspection? Staff reported that they have been issued with new improved uniforms making it more comfortable to work. Since the last inspection a number of rotten windows doors have been replaced. Work has started on the strengthening the roofs in units 3 and 4. The ceilings will then be repaired as required by previous inspections. It is anticipated that work will be completed by 1st April 2008. The service has recently been awarded a 4 star rating for very high standards of compliance with food safety legislation following a visit from Environmental Health Department. The management of medication is much improved. A number of staff have attended training in person centred planning (PCP`s) which has increased staff`s knowledge and promoted health and wellbeing of service users. What the care home could do better: A number of staff spoken with considered that staffing levels could be improved. One survey stated, "Communication between managers and staff could be improved. A more positive response to concerns other than `budget or no money` and everyone should be made to feel valued and equal".Other people considered more activities to keep people occupied on the units should be made available. Staff spoken with appeared happy in their work however it was reported that staff morale is low due to organisational changes. A briefing session for managers was held following the inspection. It is considered that the service is currently performing very well, setting its own objectives for continual improvement therefore only recommendations were made as a result of this unannounced inspection. CARE HOMES FOR OLDER PEOPLE Woden Resource Centre Vicarage Road Wednesfield Wolverhampton West Midlands WV11 1SF Lead Inspector Rebecca Harrison Key Unannounced Inspection 10:00 15th 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 Woden Resource Centre DS0000035904.V346325.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. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woden Resource Centre Address Vicarage Road Wednesfield Wolverhampton West Midlands WV11 1SF 01902-553494/8 01902 553496 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) www.wolverhampton.gov.uk Wolverhampton City Council Paul John Watling Care Home 26 Category(ies) of Dementia (7), Physical disability (19) registration, with number of places Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Age range 50 Unit 3, 7 service users; unit 4, 7 service users; unit 5, 8 service users; unit 6, 4 service users 17th July 2006 – KEY INSPECTION 9TH March 2007 – RANDOM INSPECTION Date of last inspection Brief Description of the Service: Woden Resource Centre is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of twenty-six adults. The service provides a rehabilitation unit, a reenablement unit for hospital discharges only and a respite unit for physically frail older people. The service is managed by Wolverhampton City Councils Social Services Department. Mr Brian O’Leary is the responsible individual. Mr Paul Watling is the registered manager of the residential service, the domiciliary care service and the day care service. This inspection focussed on the residential service only. The centre was opened in February 2001 in a purpose-built building, which was constructed in the early 1970’s. Residential accommodation is based on the ground floor providing 26 single bedrooms across four units. En-suite facilities are not provided. Each unit has a lounge, dining room and a small kitchenette with access to well maintained gardens. Woden is accessible by public transport. The Centre is situated close to the centre of Wednesfield and a short distance from Wolverhampton City Centre. People can obtain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk Fees charged are based on an individual financial assessment of need, co-ordinated by the social work team. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 15th October 2007 by two inspectors over a period of six hours. Following a series of medication issues our pharmacist inspector undertook a full audit of the homes medicines management systems on 9th March 2007 and a report based on his findings was sent direct to the provider. A range of evidence was used to make judgements about this service to include a self-assessment completed by the provider and sent to us, a tour of the residential service, discussions with service users, visiting relatives, the staff and managers. We also looked at a number of records and observed aspects of care provided for two people using the service. As part of the inspection we received eleven surveys from people who use the service, visiting relatives and staff on duty. Their comments are reflected throughout this report. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Older People and to review the five requirements made at the previous key inspection of 17th July 2006 and the nine requirements made by our pharmacist inspector during a random unannounced inspection on 9th March 2007. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The service is effectively managed. The manager is supported by Team Leaders who have well defined designated roles and responsibilities providing a good quality service to the people accommodated. Staff have a good understanding of the individual needs of the people using the service, which given the number of people accessing the service throughout the year it is a credit to the staff and managers. The self-assessment completed by the manager and sent to CSCI was detailed and acknowledged the strengths, weaknesses and plans for service improvement. Infection control procedures adopted by staff are robust and help to safeguard the numerous people using this service from risk of infection. The centre was found very clean and tidy throughout this unannounced inspection. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 6 Record management systems are a credit to staff and managers. All records examined as part of this inspection were easily accessible and presented to an exceptional standard. Views gained during the inspection and compliments the service has received include: “All the staff are very helpful and courteous…its what makes a stay a happy affair”. “Carers and staff are excellent” “Woden is like a hotel, it’s beautiful. The staff are so friendly and helpful and the food is delicious…I am so grateful of such a wonderful service” “I would like to express my thanks to all the staff for the courtesy they have shown to me. Bedrooms are very clean, meals have been excellent…” “The standard of service is excellent and everyone always very pleasant”. What has improved since the last inspection? What they could do better: A number of staff spoken with considered that staffing levels could be improved. One survey stated, “Communication between managers and staff could be improved. A more positive response to concerns other than ‘budget or no money’ and everyone should be made to feel valued and equal”. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 7 Other people considered more activities to keep people occupied on the units should be made available. Staff spoken with appeared happy in their work however it was reported that staff morale is low due to organisational changes. A briefing session for managers was held following the inspection. It is considered that the service is currently performing very well, setting its own objectives for continual improvement therefore only recommendations were made as a result of this unannounced inspection. 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. Woden Resource Centre DS0000035904.V346325.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 Woden Resource Centre DS0000035904.V346325.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): 1,2,3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are provided with detailed information to decide whether this service will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. People assessed and referred solely for intermediate care are helped to maximise their independence and return home. EVIDENCE: The service has a clear and comprehensive Statement of Purpose and Service User Guide in place, which was last reviewed and updated in April 2007. An information pack is provided in each bedroom containing both documents in addition to a number of leaflets informing them of other services provided by the Council and contact details. A relative who spoke to us considered that Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 10 she was provided with detailed information prior to her mother being admitted to the service. The Centre also provides an Information Shop where service users and carers can access a range of information about the centre and other service available. The admission procedure was discussed with the Care Co-ordinator who demonstrated a good knowledge of the assessment, admission and care planning process. A contact folder for each unit provides staff with concise and up to date information on each person placed in the unit. The self-assessment completed by the provider states ‘where possible all service users receive a full multi-disciplinary assessment prior to admission. In some cases such as emergency admissions this is not possible but will be completed within the given timescale if necessary’. The needs assessments for one person, receiving a service on the rehabilitation unit and one person placed on the respite was examined and found detailed. Individuals are provided with a detailed Service Agreement setting out the obligations of the provider, local authority and service user. Woden Resource Centre DS0000035904.V346325.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans provide staff with the detailed information required to satisfactorily meet the health and personal care needs of the people using the service. Medication systems have improved but must be kept under review to ensure people are not placed at risk. People who use the service are treated with respect and dignity. EVIDENCE: The care documentation held on behalf of one person accommodated in the rehabilitation unit and one person placed in the respite unit was examined. There was evidence that care plans had been generated by needs assessments and were detailed however did not clearly evidence that plans had been developed in partnership with the service user and representative, this was Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 12 fully acknowledged by the Co-ordinator who committed to improving this area. It was reported that since the last inspection a number of staff have attended training in person centred planning (PCP’s) which has increased staffs knowledge and promoted health and wellbeing of service users. It was reported that staff have developed positive working relationships with health and social care professionals. Multi-disciplinary meetings are held weekly to discuss individual progress and identify any necessary changes to care plans or service delivery. Managers are working towards all care staff are aware of the outcomes of these meetings. Health care needs were clearly identified on the two care records examine and staff are responsible for maintaining a daily journal on each individual with regard to their health and personal care. Manual handling risk assessments were available on the two files examined. Following a series of medication issues our pharmacist inspector undertook a full audit of the homes medicines management systems on 9th March 2007. A number of shortfalls were identified concerning staff not fully adhering to the organisation’s medication policies and procedures document, record keeping, administration and storage. As a result of this nine requirements were made and a report of the findings sent direct to the provider. An inspector spent time with the Team Leader with designated responsibility for medication and reviewed the nine requirements made and examined all Regulation 37 notifications concerning medication sent to CSCI as further medication errors have occurred following our pharmacist inspection. Records examined clearly identified that thorough investigations had been undertaken with a clear audit trail appropriate action taken where required. It is considered that the management of medication has improved overall however the management of medication needs to continue to be closely monitored to ensure systems are effective and safeguard people. It was reported that all staff responsible for administering medication have undertaken and obtained the certificate in safe handling of medicines via a local college. Managers were advised to ensure the control drugs cupboard is rag bolted to an external wall. A member of staff spoken was able to evidence how work practices promote peoples dignity and privacy and staff were seen to knock on bedrooms doors during the inspection. Service users were very well presented and looked relaxed in the presence of staff. Surveys completed by service users and visiting relatives indicate that staff are very helpful and courteous. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service can choose to participate in social activity and are encouraged to maintain contact with their family and friends. Menus provide choice and variety taking into account special dietary needs and personal preferences. EVIDENCE: The self-assessment forwarded to us states ‘Given the nature of the service, routines, activities and plans can be changed to meet individual changing needs and choices. Helping people to maintain or regain daily living skills is a large part of the work of the Centre’. Discussions held with people using the service and visiting relatives confirmed this however feedback received indicates that although people have access to a large day centre located on site, more could be done to provide structured activities both within the units and the local community. Special events and celebrations are held and themed menus provided such as St. Georges Day, American Independence Day etc which have provided very successful. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 14 People have access to committee meetings in addition to a number of services to include advocacy, carer support, bereavement and an information service. People spoken with stated they were very satisfied with the service and reported they are encouraged to maximise their independence over their own individual lifestyles as far as possible. Discussions held with visiting relatives during the inspection evidenced that they are welcome to visit, no restrictions are placed on visiting times and the staff communicate well with them. We received surveys from three relatives and their comments were very complimentary and include: “Staff do a really good job caring for the residents” Good care, friendly staff, clean rooms and nice food” “Home from home”. “Nothing could be done better”. People spoken with confirmed they are enabled to exercise choice and control wherever possible and that daily routines are flexible. Training records evidence that two managers have recently attended training in the Mental Capacity Act. Bedrooms seen indicate that people can bring small personal possessions in with them during their stay if they wish. The service operates a four-week rolling menu, which appeared balanced and varied. People spoken with were very complimentary about the meals provided and ‘themed’ days prove positive. The centre provides a restaurant where service users are encouraged to use the self-serve facility however staff are available to provide assistance where required. The dining area appeared comfortable and friendly and was immaculately presented. The service has recently been awarded a 4 star rating for very high standards of compliance with food safety legislation following a visit from Environmental Health Department. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are able to express their concerns and have access to an effective complaints procedure. Appropriate procedures are in place to safeguard service users from potential abuse. EVIDENCE: People have access to Wolverhampton City Council’s corporate complaints policy and procedure, which is available in a number of formats and readily available. The complaints procedure is also documented in the service user guide and an information leaflet is provided in service users own private accommodation. A Suggestion Box is held in the main reception. Managers are responsible for completing monthly returns for all complaints and compliments received and a copy of these are then sent direct to the Customer Relations Manager. Since the last inspection seven complaints have been received and investigated. It was reported that there are no outstanding complaints. Since the last inspection we have not received any concerns or complaints regarding this service. Numerous thank you cards were seen displayed around each unit and the service regularly receive verbal and written compliments as seen documented. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 16 The service has access to the local safeguarding adults policy and procedures located in the staff room and duty offices. It was reported that all staff have received training in adult protection reporting and recording and are due to attend refresher training shortly, which will include the recently updated Safeguarding Adults Policy and Procedure. It was stated that training in the management of actual and potential aggression (MAPA) is not a priority for this service. Since the last inspection one person has been subject to safeguarding adult procedures and a strategy meeting held. This was discussed at length with the manager who reported that although the case has since closed a disciplinary hearing is due to be held in November 2007 following an internal investigation into the circumstances. It was reported that the service has recently started working with the West Midlands Police Force. People using the service are asked if they wish to partake in interviews as part of police training in safeguarding adults. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service are provided with clean and comfortable accommodation appropriate to their individual needs and encouraging their independence. EVIDENCE: Twenty- six registered beds are provided across four units. All areas of the service are fully accessible to people who are wheelchair dependent. Bedroom sizes fall below national minimum standards but they are comfortably furnished and can be equipped to meet the individual needs of each person accommodated for short periods. People are offered keys to their bedrooms on arrival unless a risk assessment determines otherwise. Each unit has a lounge, dining room and a small kitchenette with access to well maintained gardens. People using the service have access to a day care centre provided on site. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 18 Since the last inspection a number of rotten windows doors have been replaced. Work has started on the strengthening the roofs in units 3 and 4 and ceilings will then be repaired as required by previous inspections. It is anticipated that work will be completed by 1st April 2008. Procedures for the management of infection control were discussed with the Team Leader responsible for the programme. Evidence seen throughout the inspection clearly indicate that the procedures adopted by the service are robust in safeguarding service users and staff from the risk of infection. Staff receive training in infection control procedures as part of their induction. Regular audits are undertaken to ensure all staff follow the robust procedure ensuring the safety of the numerous individuals who access this service. Five domestic staff are employed and have undertaken distance-learning training in infection control procedures. Certificates were seen displayed which indicate that a laundry assistant holds National Vocational Qualifications at levels 1 and 2 in Cleaning and Support and has attended distance learning training in infection control and safety compliance. At the time of this unannounced inspection the cleanliness of the service was a credit to all staff. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service provides a well-trained and committed staff group who work positively improving service users quality of life during their stay. The recruitment procedures adopted by the department are currently under review to ensure they are robust and fully safeguard service users. EVIDENCE: Staff spoken with had during the inspection had a good understanding of the needs of the people in their care and interacted positively with service users throughout the day of the inspection. All service users and visiting relatives spoken with were very complimentary regarding the service and the care provided which was also reflected in the surveys that we received. The organisational structure of the team is included in the homes Statement of Purpose. The care team consists of a registered manager, three team leaders with designated areas of responsibility, one Co-ordinator, assistant team leaders and rehabilitation assistants. It was reported that the current staffing ratio is usually six care staff covering four units, which was an accurate reflection of the staff on duty at the time of the inspection. The rota identified shortfalls however it was stated that staffing is based on the numbers of people accommodated at any time and the dependency levels. Staffing Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 20 shortfalls is supplemented from the home support and day care service or by staff working additional hours. The service currently has vacancies for two rehabilitation assistants and one assistant cook. It was reported that the service is not recruiting any new staff due to budget implications therefore permanent staff are covering vacant hours. Two of the surveys that we received suggest staffing levels could be improved, which was also suggested by some staff spoken with. The service has experienced some levels of staff sickness however it was stated “Attendance has improved immensely but staff morale has been a bit low due to the concerns over the restructure of older peoples services”. It was stated that no new staff have been recruited since 8th August 2005 therefore no new personnel records were available for inspection. A personnel file was selected to examine training records and certificates and the file was found organised and well presented. Discussions held with the Team Leader who has designated responsibility for human resources and staff training had a clear understanding of her role and responsibilities and is clearly very committed to her job. Two of our inspectors visited the Civic Offices on 9th July 2007 to audit a selection personnel files and a number of shortfalls were found in the recruitment of some new employees who work in care settings across the authority. The findings evidenced that the registered provider is not consistent with its recruitment process in maintaining the relevant documentation required by the Care Homes Regulations 2001, as amended, potentially placing people who use services at risk. A meeting has since been held between Council officers and CSCI and the provider have committed to improving recruitment and recording procedures across all services. It was reported that of the 21 care staff employed across the residential units, 24 staff hold NVQ qualifications; this exceeds the National Minimum Standards. Staff training needs are identified through the employee performance reviews and during formal supervision. Such needs are then logged onto the training plan and nominations put forward to the training department. A member of staff spoken with stated, “Staff have excellent training opportunities…Woden is very privileged”. A staff award ceremony is held annually in recognition of their achievements. Training records evidenced that staff receive regular training appropriate to their role and in safe working practices. The service has a Team Plan in place and staff spoken with reported that they receive the necessary training appropriate to their role and are in receipt of formal supervision. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager is supported well by his senior staff in providing clear leadership throughout the service with all staff demonstrating an awareness of their roles and responsibilities providing positive outcomes for service users. Aspects of performance are regularly reviewed and the premises are managed and maintained in a manner, which ensures the safety of service users. EVIDENCE: Mr Paul Watling is the registered manager of the service holds overall responsibility for the residential, day and domiciliary care services provided through the Resource Centre. Mr Watling has twenty-four years experience in Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 22 social care and holds the Registered Managers Award, NVQ in 4 Care, Diploma’s in Management and Supervisory Management in addition to a Degree in Business Administration. He has also attended training in Health and Safety and Dementia Care Mapping. Staff spoken with reported that the manager is approachable and supportive. There is evidence that the ethos of the home is open and transparent. The self-assessment forwarded to us prior to the inspection states ‘The centre has a range of auditing and monitoring systems and uses the information to ensure that practice is safe… We regularly issue service users with questionnaires to request feedback. These are then analysed and views taken into account when planning changes’. Managers were able to clearly evidence the systems in place and detailed reports incorporating the views of service users and staff were seen documented by the Quality Assurance Reviewing Manager. The views of both service users and staff are listened to. Quality assurance systems are robust and evidence of the latest audits were available to include an annual performance report. The management of service users finances was discussed with a Team Leader who stated that current procedures are “robust as far as they can practicably be”. All monies held on behalf of individuals are recorded and all transactions signed and dated by two staff and records regularly audited. Managers were advised to ensure care plans reflect financial management. Service users are provided with lockable facilities in their bedrooms. The requirement previously made in relation to staff receiving formal supervision is considered met. Staff spoken with confirmed that they have regular supervision with their line manager and systems have been developed to record these. Regular staff meetings are held and minutes kept. All records examined as part of this inspection were easily accessible and presented to an exceptional standard. The service has a full range of policies and procedures to promote and protect service users’ health and safety. Records evidence that safety checks are carried out at the required frequency and that staff receive training in safe working practices. Certificates evidence that equipment is serviced however managers were advised to ensure that a copy of the gas and hardwiring certificates are held on site. All accidents are recorded and an annual report submitted to the manager. Risk assessments for safe working practices are available however managers were advised that outdated assessments be disposed of to ensure staff are all working to the most current assessment. The manager was advised to develop a first aid risk assessment and ensure staff responsible for bedside assemblies receive appropriate training. Most of the manager’s hold the Managing Safety IOSH certificate and staff spoke with confirmed that they are happy with the health and safety Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 23 procedures in place. There are no outstanding requirements made by the Fire or Environmental Health Departments. Woden Resource Centre DS0000035904.V346325.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 4 3 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 4 3 Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes – but actioned 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. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard OP7 OP38 Good Practice Recommendations Care plans should evidence service user involvement and how finances held on behalf of service users is managed. Risk assessments that have been reviewed and updated should be made accessible to all staff. Assessments no longer in use should be removed from the working file. This will ensure staff work with the most current information and help to safeguard the people who use the service and staff. Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woden Resource Centre DS0000035904.V346325.R01.S.doc Version 5.2 Page 27 - 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. 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