Care Home: Woodberry Grove

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What the care home does well The home provides consistently good outcomes for people. We found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The home provides a statement of purpose that is specific to the home and the resident group that they care for. The statement of purpose confirmed that the cultural and religious needs of people would be respected. People are supported to maintain their cultural and religious identity. A person who lives at the home said, "The manager visited me and asked what help I needed." Admissions are not made to the home until a full needs assessment has been undertaken to ensure the best outcomes for people. A person spoken to told us "staff are kind and caring." Care plans make sure that people`s needs are addressed in a person centered way. Detailed manual handling and general risk assessments are in place. Management of risk ensures that safety issues are addressed whilst at the same time improving the quality of life for people living at the home. People spoken to told us that activities are provided regularly. People are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. There were policies on handling abuse and protection. People feel safe and well supported by the home, which has their protection and safety as a priority. People spoken to felt that staff had the necessary skills to meet their needs. Staff are supported through training to meet the individual needs of people. The registered manager has extensive experience of managing a service for older people. The registered manager has a clear understanding of how to deliver good outcomes for people living at the home. What has improved since the last inspection? There were three areas for improvement identified at the last inspection. Since the last inspection the medication of all people living at home who have dementia has been reviewed. We saw that this was recorded in their medical notes. People living at the home who have dementia receive the medication necessary to support their continued health and well-being. At the last inspection staff files were not in good order. The registered manager explained that she had reorganised the staff files to make them easier to use. We found that the two staff files we looked at are wellorganised with all the relevant information. The home recognises the importance of effective recruitment procedures in the delivery of a quality service and to protect people. Since the last inspection a certificate has been obtained to confirm that the home`s electrical system is safe. We were able to see the certificate and it showed that the home electrics were safe. Health and safety checks make sure that people living in the home are safe. What the care home could do better: No areas for improvement have been identified at this inspection. CARE HOMES FOR OLDER PEOPLE Woodberry Grove 91 Wellington Road Bush Hill Park Enfield Middlesex EN1 2PW Lead Inspector Tony Brennan Unannounced Inspection 11:30 30th July 2008 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 Woodberry Grove DS0000010638.V366197.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. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodberry Grove Address 91 Wellington Road Bush Hill Park Enfield Middlesex EN1 2PW 020 8360 2214 020 8886 9296 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.sherwoodhousecare.co.uk Hapee Care Ltd Mr Kathiresu Cumareshan Mrs Janet Carol McGuigan Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2006 Brief Description of the Service: Woodberry Grove is a care home registered to provide a service for 26 older people. The service has recently been granted registration to provide dementia care services. A respite care service is also provided. The stated aim of the service is to provide a high standard of individual care, support and a pleasing environment for all the residents to enjoy a good quality life. Woodberry Grove is a private care home owned by Mr Cumaresham of Hapee Care Limited. Mr Cumaresham owns a number of other care homes in England. The service is provided in a large detached property with rear extension that has been converted for use as a care home. There are eighteen single bedrooms and four double bedrooms. Bedrooms are on the ground, first and second floor with a shaft lift serving all three floors. In addition, there is a chair lift linking the ground and first floors. There are bathrooms on all three floors. There are two lounge areas and a dining room on the ground floor and a room on the second floor which is used by the hairdresser and can also be used by staff and service users as a sitting area. There is a garden to the rear which includes a grassy area with trees and shrubs as well as a paved area with seating for residents. Woodberry Grove is in an quiet road in an attractive residential area of Bush Hill Park, Enfield. It is close to local shops, a railway station and bus routes. The provider must make information available about the service, including reports, to service users and other stakeholders. Fees for the home range between £345.00 - £485.00 per week. Woodberry Grove DS0000010638.V366197.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 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was undertaken as part of the annual inspection programme. We sought to confirm that the three areas for improvement identified at the last inspection had been addressed. Prior to the inspection the home had completed its Annual Quality Assurance Assessment. The Annual Quality Assurance Assessment provided us with information about the home and how it was seeking to provide the best outcomes for people. We also looked at any other information we had received about the home since the last inspection. This included any information regarding incidents that the home had told us about. The inspection took place over two days. We were assisted by the acting manager, Janet McGuigan, with the inspection. We spoke with six people who live at the home, and four members of staff. We observed care practice and interaction between staff and people living at the home. We toured the building and examined a number of records relating to the care, health and safety and management of the home. At the end of the inspection feedback was given to the registered manager, and areas for improvement were discussed. We would like to thank the staff that assisted us by answering questions about the running of the home. We would also like to thank the people who live at the home who discussed their views of the service they receive. What the service does well: Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 6 The home provides consistently good outcomes for people. We found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The home provides a statement of purpose that is specific to the home and the resident group that they care for. The statement of purpose confirmed that the cultural and religious needs of people would be respected. People are supported to maintain their cultural and religious identity. A person who lives at the home said, “The manager visited me and asked what help I needed.” Admissions are not made to the home until a full needs assessment has been undertaken to ensure the best outcomes for people. A person spoken to told us “staff are kind and caring.” Care plans make sure that people’s needs are addressed in a person centered way. Detailed manual handling and general risk assessments are in place. Management of risk ensures that safety issues are addressed whilst at the same time improving the quality of life for people living at the home. People spoken to told us that activities are provided regularly. People are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. There were policies on handling abuse and protection. People feel safe and well supported by the home, which has their protection and safety as a priority. People spoken to felt that staff had the necessary skills to meet their needs. Staff are supported through training to meet the individual needs of people. The registered manager has extensive experience of managing a service for older people. The registered manager has a clear understanding of how to deliver good outcomes for people living at the home. What has improved since the last inspection? There were three areas for improvement identified at the last inspection. Since the last inspection the medication of all people living at home who have dementia has been reviewed. We saw that this was recorded in their medical Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 7 notes. People living at the home who have dementia receive the medication necessary to support their continued health and well-being. At the last inspection staff files were not in good order. The registered manager explained that she had reorganised the staff files to make them easier to use. We found that the two staff files we looked at are wellorganised with all the relevant information. The home recognises the importance of effective recruitment procedures in the delivery of a quality service and to protect people. Since the last inspection a certificate has been obtained to confirm that the homes electrical system is safe. We were able to see the certificate and it showed that the home electrics were safe. Health and safety checks make sure that people living in the home are safe. 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. The summary of this inspection report can be made available in other formats on request. Woodberry Grove DS0000010638.V366197.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 Woodberry Grove DS0000010638.V366197.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): 13 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home and relatives are helped to decide if Woodberry Grove is the right home for them by the quality of the information (including at visit to the home) they are given about the home People’s needs are assessed prior to admission to the home to make sure they receive the care and support they need. National Minimum Standard number 6 is not applicable to this service, as the home does not provide intermediate care. EVIDENCE: Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 10 We found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The annual quality assurance assessment stated that the home has a comprehensive statement of purpose. A person who lives at the home said, “ this is a very well run place.” The statement of purpose also identified the skills and staffing resources available to meet the needs of people. The home is registered to provide care for people with dementia. We found that training records showed that staff had attended a number of courses so that they had the skills to meet these needs. Staff spoken to was able to explain in detail how they met the needs of people who have dementia. The home provides a statement of purpose that is specific to the home and the resident group that they care for. The statement of purpose confirmed that the cultural and religious needs of people would be respected. Records show that people were supported by the home to maintain contact with their church or other community groups. A person who lives at the home told us, “ I can go for a walk when I want to.” We spoke with the registered manager told us that cultural and religious needs would be addressed and identified through initial assessments and care planning. The initial assessment for one person case tracked stated that she was a practising Christian. She told us that she was able to attend a weekly service. This was highlighted in her care plans. People are supported to maintain their cultural and religious identity. People living at the home have varying degrees of disability. The environment has been adapted so that it is accessible. We observed that people were able to move about the home safely. People had their photograph on their bedroom doors to help them identify their bedrooms. The homes environment is adapted to meet the individual needs of people. The annual quality assurance assessment stated that there were comprehensive pre admission assessments in place. We found that there were detailed assessments of people needs. The people case tracked had both assessments from placing authorities, and ones carried out by the home. As part of the assessment process information on the needs of people had been obtained from health professionals. This had been used to inform the home’s own assessment. Admissions are not made to the home until a full needs assessment has been undertaken to ensure the best outcomes for people. Initial assessments recorded the involvement of people and their representatives in identified the areas where they needed support. Both relatives and people living at the home told us that they had been actively involved in the initial assessment process. Detailed initial assessments are carried out with the involvement of people and their representatives to make sure their needs are identified. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 11 A person told us, “ Staff are very helpful.” Care staff spoken to were able to explain the individual needs and preferences of the three people case tracked. Staff spoken to were able to explain in detail how they met the needs of people who have dementia. Training records showed that staff had completed some training on meeting the needs of people with dementia. Admissions to the home only take place when staff have the necessary skills to meet the assessed needs of perspective residents. Woodberry Grove DS0000010638.V366197.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 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal, social and medical care needs are fully planned for. People who use the service are fully protected by safe procedures for handling medication. Peoples right to privacy is supported. EVIDENCE: We found that the care plans of all the people case tracked were detailed and clearly identified how their needs would be met. Care plans were based on initial assessments of the people case tracked. A person spoken to told us “staff are caring. Staff understands how to look after me.” There were clearly defined actions highlighted in the care plans to meet the needs of people. The care plan for one of the people case tracked highlighted that he had dementia. His care plan clearly outlined how this affected his memory and behaviour (e.g. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 13 moving around). His care plan explained how staff should respond to these needs. Care plans had been reviewed. Care plans make sure that people’s needs are addressed in a person centred way. We found that people’s choices and preferences are recorded in their care plans. The care plans for the people case tracked were found to reflect their choices and preferences. People commented that they had been asked about how they wish to be supported by staff. Staff were observed to interact respectfully and cheerfully with the people. People spoken to said that staff respected their privacy and treated them with respect. One person told us that she liked to spend time alone in her room. She said, “Staff understand I like to be alone.” This was reflected in her care plan. People we spoke to told us that they felt staff understood their needs. A key work the system is in place. We observed that staff spent time talking with people. Care plans were personalised, and referred to the cultural needs of people. This included whether or not they wish to take part in religious services. There were also personal histories that provided information on peoples interests and previous occupations. People are involved in the planning of their care that affects their lifestyle and quality of life. Each care plan includes manual handling and general risk assessments. Equipment had been provided to assist people to mobilise safely and independently. Management of risk ensures that safety issues are addressed whilst at the same time improving the quality of life for people living at the home. Diary notes showed that appropriate medical attention and advice is sought. Diary notes also confirmed that the people case tracked had access to their General Practitioner when necessary. A person told us, “The doctor visits when you need them.” Where the General Practitioner had recommended specific medical interventions these were followed up. People’s health is promoted to ensure their continued well-being. Since the last inspection the medication of all people living at the home who have dementia has been reviewed. We saw that this was recorded in their medical notes. Where necessary medicines have been changed to better meet the needs of people. People living at the home who have dementia receive the medication necessary to support their continued health and well-being. The records of medicines received, administered and returned to the pharmacist were all complete. We found where the General Practitioner had made changes to peoples medication this was signed to confirm the change had been made. We found that the medication for each of the people case tracked was accurately recorded. Medication records are fully completed, contain the required entries, and are signed by appropriate staff to ensure peoples safety. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 14 Medicines were stored safely. All medicines are stored at the appropriate temperature. Separate records were maintained for controlled drugs. Regular management checks are carried out to make sure that medication is administered safely to people. Training has been provided on the safe administration of medicines. We spoke with staff and found they were clear about their responsibilities and how to handle medicines safely. Training records also contained certificates confirming that this training had taken place. We were able to observe staff administering medication, and confirmed that this was done safely. Staff understands how to administer medication safely to people living at the home. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are provided with varied activities to meet their needs. People living at the home are supported to maintain contact with relatives and other representatives of their choice. The menu reflects the preferences of people living at the home and offers a balanced diet. EVIDENCE: Woodberry Grove has consistently provided a range of activities that meet the needs of people living at the home. We spoke with people who live at the home who told us that they are provided with regular activities. One person told us, “There are a lot of activities to do.” We observed that activities were taking place at various times throughout the day. On the afternoon of the first day of the inspection a barbecue took place. People living in the home and relatives were seen to enjoy this. A sing a long was also organised for the people in the home. People who live in the home appeared to enjoy this. Peoples’ interests were recorded as part of their care plans. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 16 The annual quality assurance assessment highlighted that as part of the activities that are provided a reminiscence group had been establish. The registered manager explained that she had decided to establish the group after attending training on dementia. She showed us examples of the groups work. This was detailed and showed that people had shared information about their lives. One person lives at the home commented, “ The reminiscence group is very good. I find the group very enjoyable.” The registered manager explained that she will be looking at ways to expand the work on reminiscence. This will involve more people living at the home. People are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. We observed that staff spend time talking with people who live at the home and listening to what they had to say. Staff spoken to understood the importance of one-to-one contact for people. One person said, “ Staff are very friendly. One of the staff is very helpful and takes time to talk with me about the news.” Relatives commented that there were no restrictions on visiting the home. People told us that they could see visitors in private if they wish to. Diary notes showed that people had regular contacts with family, friends and the wider community. The menu showed that options are offered at each meal. The menu is varied offering a number of choices of meals. We spoke with people who were generally pleased with the quality of the food provided. A person who lives at the home said, “ the food is very good”. Another person commented about the choice of food offered and that staff, “ do bring an alternative if whats on the menu is not to your taste.” people are offered a variety of meals that reflect their personal preferences and meet their dietary needs. Meals were balanced and nutritious. We observed that meals were well presented and they were provided in a relaxed manner. People were supported to eat. This was done at the pace of the people being assisted. People are able to enjoy the food they prefer and like. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are confident that their complaints will be listened to, taken seriously and acted upon. The home’s procedures protect people from abuse. EVIDENCE: The annual quality assurance assessment confirmed that a clearly defined complaints policy with agreed timescales for managing complaints was in place for people to use. We found that the details policy was in place. People living at the home told us they had received a copy of the complaints policy. They said that they knew how to make a complaint. No complaints had been referred by the Commission to the home since last the key inspection. A complaints book is available to record all concerns, allegations and complaints. We found that the complaints book recorded the actions that had been taken to address issues. The complaints record showed actions taken to resolve complaints. People with whom we spoke confirmed that they knew how to make a complaint. A person told us, “I know I can talk to the manager if I had a complaint.” The home has an open culture that allows people to express their views, and concerns in a safe and understanding environment. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 18 There were policies on handling abuse and protection. People living at the home felt confident that any concerns they raised would be handled sensitively and appropriately. A person told us, “ I can tell staff about anything that upsets me.” There had been one adult protection issue since the last key inspection. This had resolved, it was found to be not proven. The home’s management had co-operated fully with the investigation. We found that staff had received training on adult protection. Staff spoken too could recognise the signs of potential abuse, and how they would respond to it. People feel safe and well supported by the home, which has their protection and safety as a priority. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that provides a safe and homely environment. The home is clean and hygienic. EVIDENCE: We walked round the home and found that it was appropriately furnished. We found that Woodberry Grove is being well maintained. We observed that people were able to access all areas in the home safely. All bathrooms and toilets were adapted so that people with physical disabilities could access them. The home has the necessary adaptations to support people to move around safely. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 20 There are dining and sitting areas for the use of people. Two flat screen televisions had recently been purchased and were available in the sitting rooms. The registered manager had highlighted in the homes annual quality assurance assessment that new curtains and armchairs have been bought. We found that these were in place in the home. The garden is accessible and well presented. The home provides an accessible and safe environment for people to live in. As a number of people who live at the home have dementia the environment has been adapted to meet their needs. We found that a neutral colour scheme had been used throughout the home. Bedroom doors had been painted a specific colour to help people identify their bedrooms. Photographs of people had been taken and put on the bedroom doors to help them find their rooms. The home is adapted to meet the needs of people who have dementia. Bedrooms were personalised with items of furniture and pictures belonging to people. Bedrooms are decorated to a high standard. Bedrooms had been recently decorated. People told us they had been asked about the colour scheme for their bedrooms. A person told us, “ I was asked about how I wanted my room decorated.” The registered manager explained that new bedroom furniture had been purchased recently. We observed that this was available in people’s bedrooms. One person said, “ I have a very nice bedroom. I have my pictures and other things there. ” People are encouraged and supported to personalise their bedrooms. The maintenance records show that ongoing maintenance of the homes environment addressed. The registered manager explained that the company has a dedicated maintenance team. Any repairs are dealt with quickly to ensure the comfort and safety of people. The building and grounds have a rolling maintenance programme. The registered manager was able to show that a new carpet was being purchased from the ground floor hallway. The boiler is also to be replaced and a conservatory will be built at the back of the home the convenience of people living at the home. The home is maintained to a high standard to ensure people’s safety and comfort. Appropriate measures are in place to prevent cross infection. The home has detailed policies on the prevention of cross infection. Staff have received training on infection control measures. Staff spoken to understood how to work to minimise the possibility of cross infection. Staff confirmed that they had access to disposable gloves and aprons. Liquid soap and paper towels were available throughout the home. Effective infection control measures are in place to ensure the safety of people living at the home. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Sufficient staff are always available to meet the needs of people who live at the home. Staff do have all the skills to meet all the assessed needs of people who live at the home. People who live at the home are protected by the home’s recruitment practices. EVIDENCE: The rota showed that a consistent staffing level was being maintained in the home. This confirmed that sufficient staff are available to meet the needs of people. Staff said that the current staffing level allowed them to meet the needs of people. People living at the home told us that staff are available to meet their needs. We observed that staff were available at key times of the day (e.g. mealtimes) to assist people. Staff were also observed to spend time with people both individually and in small groups. This allowed more attention to the individual needs of people. There is consistently enough staff available to meet the needs of people living at the home. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 22 The annual quality assurance assessment highlighted that staff had been on a range of courses. People spoken to felt that staff had the necessary skills to meet their needs. One person said, “ Staff are great and helpful.” Training records showed that staff had been on a range of courses relating to the needs of people who live at the home. We found that these included training on dementia. Also been on training on person centred care. We observed that staff knew and how to care for people with dementia. Staff are supported through training to meet the individual needs of people who live in the home. The annual quality assurance assessment showed that at present over 50 of staff have achieved the National Vocational Qualification in care. The home has managed to maintain this consistently over two inspections. Staff training records showed that staff had done training on essential areas, such as food hygiene, health and safety, and administration of medication and infection control. The home ensures that all staff receives relevant training that is focused on delivering improved outcomes for people. At the last inspection staff files were not in good order. It was difficult to access the necessary information to confirm that a robust recruitment procedure was being followed to ensure people safety. The registered manager explained that she had reorganised the staff files to make them easier to use. We found that the two staff files we looked at are wellorganised with all the relevant information. The files contained all the required information relating to recruitment of these staff. Two references and a POVA first/CRB check had been obtained prior to them starting work at the home. This showed that the home followed a clear recruitment procedure that ensures the safety of people. A person who lives in the home told us that staff “could be trusted.” We found that there were no unexplained gaps in the employment history of recently recruited staff. A health check had been carried out to ensure that staff could safely meet the needs of people. The home recognises the importance of effective recruitment procedures in the delivery of a quality service and to protect people. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriate management structures are in place to ensure that people receive the care they need. People who live at the home are consulted about the quality of the service, and encouraged to make suggestions for improvement. People who live at the home have their financial interests protected by the home’s procedures. People who live at the home and staff are protected by the home’s health and safety procedures. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager has extensive experience of managing a service for older people. The registered manager has maintained and updated her skills regularly. She has a clear understanding of the key principles and focus of the service to make sure that people receive the care they need. We observed that the registered manager spent time talking to people. Any issues they raised with him were immediately addressed. The registered manager has a clear understanding of how to deliver good outcomes for people living at the home. The home has a system for obtaining the views of the quality of the service it provides. The home makes sure that any areas for improvement are addressed. A survey of the views of people who live at the home, relatives and professionals was in place. The registered manager had completed the home’s annual quality assurance assessment. This showed what further improvements would be made for the benefit of people living at the home. People who live at the home have meetings on a regular basis to discuss how they wish the home to be run. Staff meetings take place to ensure staff are aware of plans to develop the service. People’s views are sought and provide the bases for improving the quality of the service. The home does not hold money for people who live at the home. The home invoices their families or the relevant social service department for any expenditure made on their behalf. A system is in place to ensure receipts are obtained for any expenditure. People who use the service trust the home to handle their money safely. Fire drills were taking place and the fire alarm was tested regularly. We found that the fire risk assessment includes an assessment of all the potential fire risks in the home. We questioned staff on the fire safety procedures and found that they understood fire safety issues. All health and safety policies were available. Certificates for gas, legionella were in date. Since the last inspection a certificate has been obtained to confirm that the homes electrical system is safe. We were able to see the certificate and it showed that the home electrics were safe. COSHH guidance was in place and chemicals were stored safely. We discussed health and safety issues with staff and they demonstrated their understanding. The home has an effective system for monitoring accidents to ensure the safety of people who live and work at the home. The temperatures of the fridges and freezers were recorded and within safe limits. Health and safety checks, procedures and training make sure that people living in the home are safe. Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A 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 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 x X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Woodberry Grove DS0000010638.V366197.R01.S.doc Version 5.2 Page 28 - 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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