Care Home: Woodbourne

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What the care home does well Woodbourne provides sensitive and dignified support in a relaxed and gentle environment to suit the needs and older age range of the residents being accommodated. All persons consulted with regarding the home spoke positively about their experiences with the home. A sample of residents comments included: "Quite satisfied they do things well here"; "look after us the best they can which is good really" and "There is nothing that they could improve on". A visitor stated "can not speak highly enough about the place they have empathy and a feeling with the residents" and "very caring, they provide individual care".The home fosters a family environment, a health care professional said: " Family run, very friendly and welcoming, well looked after". Residents receive input form health care professionals to help meet their health care needs. A resident said: "all I have to do is say I am unwell and they take me to the Dr". Flexible in the daily routines, helps to promote resident`s choices. There is evidence that residents are treated as individuals. Residents are supported to maintain their own occupations and lifestyles. Residents said: "I have a bath or shower once a week when I want", "Free to do what I want and I sleep in at the weekends" and "Quite free to do what I want". The meals are good offering both choice and variety. Residents commented: meals are good you choose what you want"; "very good hot drinks when I want"; "Food nice we get a choice" and "Individual food the residents are given what they like". Residents live in a clean and homely environment with parts of it decorated and furnished to a good standard. Comments included : "Environment comfortable nice and clean" and "Nice room comfortable, smart well light and arranged to suit me". Residents` benefit from a stable, well-trained and enthusiastic staff team that know them and who are suitable recruited and employed in sufficient numbers as is necessary to meet their needs. Residents commented: "There is always someone around to get help from" and "keep cheerful all the time, always someone around". A consistent strong management approach ensures that both staff and residents are provided with a clear sense of leadership and direction. A sample of comments made about the manager included: "one of the best very good keeps being cheerful which I especially like, quite hardworking"; "very helpful"; "good manager seems to have everything under control" and "helpful and knowledgeable about residents". What has improved since the last inspection? In line with the previously requirement made the home has updated its policy and procedure for safeguarding adults to ensure that it provides clear guidance on the roles and responsibilities of staff. The manager reported that there is a programme of maintenance and redecoration, which has included the redecoration of several bedrooms over the last twelve months, and removal of several large trees surrounding the property. What the care home could do better: The external building and grounds are in need of further minor improvement to ensure a consistent environment throughout. The manager agreed to undertake this work within the next six months. Although it was clear that there are systems in place to self assesses the homes services and facilities these had not been undertaken in over a year and the manager agreed to instigate them over the coming months, in order to continue to identify areas for service development. The home has been required to improve the management of risks in order to improve resident`s safety. This is with particular reference to the completion of personal risk assessments and assessment of unguarded radiators. CARE HOMES FOR OLDER PEOPLE Woodbourne 1 Oakwood Rd Horley Surrey RH6 7BZ Lead Inspector Jane Jewell Unannounced Inspection 10:30 27th May 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 Woodbourne DS0000041738.V363262.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. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodbourne Address 1 Oakwood Rd Horley Surrey RH6 7BZ 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) 01293 822829 Mr Rohana Silva Mrs Sarojini Devi Silva Mr Rohana Silva Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st May 2007 Brief Description of the Service: Woodbourne is registered to provide care and accommodate up to six older people who’s primary needs are having a past or present mental health condition. The home was opened in 1985. The home is a detached converted domestic property set in a residential area and within walking distance of Horley town centre and its amenities. The communal areas comprise of two lounges (one of which is a designated smoking area) and a kitchen/dining room. There is a garden area, which surrounds the home and provides for some off road parking. Resident’s accommodation consists of single accommodation with four bedrooms having their own en-suite facilities. The home is presented across two floors with access to the first floor by stairs. The homes literature states that the philosophy of the homes is to provided a service for clients with past or present mental illness by recognising that they are individuals with their own personal needs. The fees for residential care are currently £450 to £500 per week, depending on the services and facilities provided. Extra such as: newspapers, hairdressing, chiropody, toiletries are additional costs. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is Two star. This means the people who use the service experience Good quality outcomes. The information contained in this report has been comprised from an unannounced inspection undertaken over five and half hours and information gathered about the home prior to the inspection. This includes: residents survey questionnaires, discussion with stakeholders involved in resident’s care and health care professionals. The manager had completed an Annual Quality Assurance Assessment form prior to the inspection and the information contained in this document has been used to inform the inspection of the home. The inspection was facilitated in the main by Mr Rohana Silva (Registered Provider /Manager) and the deputy manager and joint provider Mrs Sarojini Devi Silva. The inspection involved a tour of the premises, observation, examination of records and discussion with residents. There were five residents living at the home at the home at the time of the inspection. The home is inspected under the older peoples national minimum standards. The focus of the inspection was to look at the experiences of life at the home for people living there, this involved observing residents and their interactions with staff and examination of the homes facilities and documentation. Signs of residents well-being/ill-being (terminology used for observing behaviour for people who do not use verbal communication) were observed. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents, staff and management for their assistance and hospitality during the visit. What the service does well: Woodbourne provides sensitive and dignified support in a relaxed and gentle environment to suit the needs and older age range of the residents being accommodated. All persons consulted with regarding the home spoke positively about their experiences with the home. A sample of residents comments included: “Quite satisfied they do things well here”; “look after us the best they can which is good really” and “There is nothing that they could improve on”. A visitor stated “can not speak highly enough about the place they have empathy and a feeling with the residents” and “very caring, they provide individual care”. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 6 The home fosters a family environment, a health care professional said: “ Family run, very friendly and welcoming, well looked after”. Residents receive input form health care professionals to help meet their health care needs. A resident said: “all I have to do is say I am unwell and they take me to the Dr”. Flexible in the daily routines, helps to promote resident’s choices. There is evidence that residents are treated as individuals. Residents are supported to maintain their own occupations and lifestyles. Residents said: “I have a bath or shower once a week when I want”, “Free to do what I want and I sleep in at the weekends” and “Quite free to do what I want”. The meals are good offering both choice and variety. Residents commented: meals are good you choose what you want”; “very good hot drinks when I want”; “Food nice we get a choice” and “Individual food the residents are given what they like”. Residents live in a clean and homely environment with parts of it decorated and furnished to a good standard. Comments included : “Environment comfortable nice and clean” and “Nice room comfortable, smart well light and arranged to suit me”. Residents’ benefit from a stable, well-trained and enthusiastic staff team that know them and who are suitable recruited and employed in sufficient numbers as is necessary to meet their needs. Residents commented: “There is always someone around to get help from” and “keep cheerful all the time, always someone around”. A consistent strong management approach ensures that both staff and residents are provided with a clear sense of leadership and direction. A sample of comments made about the manager included: “one of the best very good keeps being cheerful which I especially like, quite hardworking”; “very helpful”; “good manager seems to have everything under control” and “helpful and knowledgeable about residents”. What has improved since the last inspection? What they could do better: Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 7 The external building and grounds are in need of further minor improvement to ensure a consistent environment throughout. The manager agreed to undertake this work within the next six months. Although it was clear that there are systems in place to self assesses the homes services and facilities these had not been undertaken in over a year and the manager agreed to instigate them over the coming months, in order to continue to identify areas for service development. The home has been required to improve the management of risks in order to improve resident’s safety. This is with particular reference to the completion of personal risk assessments and assessment of unguarded radiators. 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. Woodbourne DS0000041738.V363262.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 Woodbourne DS0000041738.V363262.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 4 and 5 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective and existing residents have information about what services are provided and what to expect when living at the home in order to help them make informed decisions. The home provides relaxed and gently lifestyles in keeping with the needs of the residents living at the home. Prospective residents would only be accommodated if the home is satisfied that their needs can be met. EVIDENCE: There is some literature about the home and the services and facilities it provides. This includes a statement of purpose and service user guide. Copies of which are provided to residents. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 10 Residents are provided with a written contract of terms and conditions of residency with the home. This can be used with residents and their representatives to make explicit the placement arrangements and clarify mutual expectations around rights and responsibilities. A signed copy of the contract is retained in resident’s files. There have not been any new admissions to the home since 2005, therefore, this standard was assessed in respect of the admission procedure for any future prospective residents. The manager was aware of the admission criteria for the home and knowledgeable about admissions practices that would ensure a range of information is gathered about prospective residents. This would then inform their decision whether a prospective residents needs could be met at the home. There is a range of residents needs being accommodated this includes some residents who live independent lives and several residents who have more complex mental health needs. The age range of residents is from 50 to 86 years, with the majority of residents having known the providers for up to fifteen years. Through observation, looking at records and speaking to stakeholders involved in resident’s lives, evidence was gathered that the home is meeting most needs of residents and provides relaxed and gentle lifestyles for the older person. All persons consulted regarding the home spoke positively about their experiences with the home, residents commented: “Quite satisfied they do things well here”; “look after us the best they can which is good really” and “There is nothing that they could improve on”. A visitor stated “can not speak highly enough about the place they have empathy and a feeling with the residents” and “very caring, they provide individual care”. A health care professional said: “ Family run, very friendly and welcoming, well looked after”. The manager confirmed that any prospective residents would be provided with the opportunity to visit the home in advance to assess the quality, facilities and suitability of the home, the type and length of any visit would depend on the needs and preferences of the perspective resident. Intermediate care is not offered at the home therefore this standard is not assessed. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a care planning system in place which provides staff with information they need to be able to meet resident’s needs, however further work is needed to the risk assessment process to ensure staff have the guidance to help maintain residents safety. Residents receive input form health care professionals to help meet their health care needs. The system for the administration of medications are good with clear and comprehensive arrangement in place to ensure residents safety. EVIDENCE: All care plans were examined and these generally provided the necessary information about resident’s needs and how to support them. Good practices were noted in the regular reviewing of care plans, which were linked to resident’s individual’s goals which enabled a clearer assessment of whether personal goals were being attained. A example of clear behavioural guidelines Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 12 was noted which provided staff with the guidance on how to support a resident when they become anxious. However, not all risked faced and posed by residents had been assessed in order to ensure that residents are able to take reasonable risks as part of maintaining an individual lifestyle. For example some residents have not been assessed for generic or specialist risks for example radiator guards, independent outings and challenging behaviour. The home has been required to undertake personal risk assessments in order to identify potential risks and any measures that can be put into place to manager or reduce the risk. The manager agreed to complete these as a matter of priority. Residents stated that they are aware of the contents of their care plan but expressed little interest in being involved in its review. The home maintains a daily record for each resident on events and occurrences. An incident reported to the inspector by a resident had not been recorded and the manager updated their notes during the course of the inspection. The manager ensures that any changes in resident’s needs and preferences are also identified through the regular review of care plans. Annual placement reviews are held with the placement authorities and residents stakeholders. Residents are supported to maintain their health needs, with care plans containing a record of any visits or contact with health care professionals. There was evidence of involvement from General Practitioners, dental hygienist, dieticians, and psychiatrists. It was clear that where there are concerns regarding the health or welfare of resident’s medical advice and intervention has been sough promptly. A resident said: “all I have to do is say I am unwell and they take me to the Dr”. The system for the administration of medication was good with clear and comprehensive arrangements in place to ensure resident’s medication needs can be safely met. During the inspection the management team were seen to be respectful and considerate to all residents and visitors, they were observed using residents preferred forms of address and knocking on bedroom doors prior to entering. Residents spoke of being able to have a key to their bedroom door it they wanted one. Woodbourne DS0000041738.V363262.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 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Flexible in the daily routines, helps to promote resident’s choices. There is evidence that residents are treated as individuals. Residents are supported to maintain their own occupations and lifestyles. The meals are good offering both choice and variety. Links with families continued to be valued and supported by the home. EVIDENCE: Much feedback was received regarding the family orientation of the home with much emphasis placed on the relaxed and gently lifestyles of residents, which was in keeping with the needs of the residents currently accommodated. Residents spoke of going out independently to the town centre and the library. Other residents are reliant on the manager driving them to local places. There is no formal activities plan instead residents in the main make their own arrangements for occupation and stimulation as part of maintaining an independent lifestyle. A health care professional said: “Activities not many Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 14 provided”. A resident commented: “Not much time to get bored as I am always doing something”. The manager spoke of the ways they try and motivate individuals to participate in various occupations and of the organised activities that have occurred including external music entertainers and religious services. The manager was aware of the need to review the current arrangements for one resident to ensure they were provided with further opportunities for occupation and stimulation. Visitors commented upon how welcomed they are made to feel during their stay, this included being offered beverages or meals and staff always being friendly and approachable. Residents spoke of their visitors being able to visit at any time. There is evidence that residents are treated as individuals. Observation of the daily routines and discussion with residents continue to confirm that staff accommodate resident’s personal wishes with regard to meal times, going to bed, rising and bathing. During the inspection residents were observed to move around the home choosing which room to be in and what level of company they wanted to enjoy with a residents saying: “I have a bath or shower once a week when I want”, “Free to do what I want and I sleep in at the weekends” and “Quite free to do what I want”. A visitor said “they do treat the residents as individuals”. The management team spoke knowledgeable about the individual needs and preferences of residents and of any cultural or religious beliefs. The inspector had lunch with residents and the management team, the meal served at inspection was presented well with resident’s individual preferences respected. Much emphasis is placed on meals providing a social occasion with the management team having their meals with residents, which residents said they preferred. A sample of comments made about the food included: “ meals are good you choose what you want”; “very good hot drinks when I want”; “Food nice we get a choice” and “Individual food the residents are given what they like”. Support has been obtained from a dietician in menu planning for a resident. Woodbourne DS0000041738.V363262.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 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. An effective complaints procedure and adult protection practices protect the rights and interests of residents. EVIDENCE: There is an accessible complaints procedure for residents, their representative and staff to follow should they be unhappy with any aspect of the service. No complaints has been received or recorded by the home since the previous inspection. All residents consulted felt confident to approach any member of staff with their concerns and felt that it would be dealt with promptly. A resident said: “if a problem would just speak to Ron” ( manager). It was previously required that the homes safeguarding adults policy and procedure be updated, although this has been undertaken the manager agreed to obtain a copy of Surrey multi agency guidelines on safeguarding adults. The manager and deputy who undertake a significant amount of staffing hours at the home have completed external training in safeguarding adults. They showed an understanding of their roles and responsibilities under safeguarding adult’s procedures. The deputy manager stated that they cascade this training to the other staff employed and staff can refer to the reporting procedures in the event of any concerns being raised. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 16 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 20 21 22 24 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment with parts of it decorated and furnished to a good standard, with some works necessary to the building in order to create a consistent environment throughout. The home ensures that residents private accommodation is equipped to provide comfort, privacy and to meet residents individual lifestyles and preferences. EVIDENCE: The home is located within walking distance of Horley town centre and its amenities. Standards of maintenance and decoration were variable throughout the home. The manager reported that there is a programme of maintenance and redecoration, which has included the redecorated of several bedrooms Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 17 over the last twelve months, and removal of several large trees surrounding the property. The external building and grounds are in need of improving. The manager had already identified these areas for improvement and stated that they plan to further improve the garden area by creating a patio area, replacing several window and repainting the external building. The manager agreed that these works would be completed within six months. Communal space consists of a dining room lounge and smoking room. Much effort is made to create a homely feel to the environment. Comments from residents and stakeholders regarding the environment include: “environment very homely” and “Environment comfortable nice and clean”. Bedrooms seen had been individualized with personal belongings. All residents consulted with said that they liked their bedroom and that they provided everything they needed. A resident commented: “Nice room comfortable, smart well light and arranged to suit me”. Residents spoke of being able to have a key to their bedroom. One bedroom has a lino flooring which was present when the building was purchased, the occupant of this bedroom did not wish for a carpet to be fitted and said that they were more than happy with their bedroom the “way it was”. There is sufficient number of toilets and bathrooms located around the home including four bedrooms, which provide en suite facilities. The home is not registered to admit residents with physical disabilities and the stairs and other access arrangements would make it unsuitable for people with significantly restricted mobility. Fitted throughout the home are call points, which enable assistance to be summoned when pressed. None of the residents said that they have had cause to use it but felt confident that their calls would be answered quickly. One call point in a bedroom could not be located and it was established that it was broken and the manager agreed to ensure its repair as soon as possible. All parts of the home visited were observed to be clean with a good standard of hygiene maintained. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a stable, well-trained and enthusiastic staff team that know them and who are suitable recruited and employed in sufficient numbers as is necessary to meet their needs. EVIDENCE: The manager and deputy undertake a significant amount of staffing hours at the home, in addition several other part time staff are employed who work occasional shifts and are predominantly registered mental health nurses. There is little to no staff turnover with the staff team consisting of family members of the providers and staff who have worked at the home for a number of years. This stability in the staff team clearly benefits residents through consistent support being provided by staff who know them. The manager and deputy manager have a significant amount of experience, training and understanding of residents needs. All residents consulted with felt that there was always sufficient staff on duty to get the support they needed. Residents commented: “There is always someone around to get help from” and “keep cheerful all the time, always someone around”. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 19 The deputy manager reported that both managers have undertaken National vocational qualification along with sufficient number of staff to ensure that at least 50 of the staff team had attained this qualification. Records showed that all of the mandatory training has been undertaken to enable staff to work safety with residents. The personal files of staff were inspected and these showed that a robust recruitment process is followed which included the use of an application form, interviews, Criminal Records Bureau (CRB) checks and written references prior to employment commencing. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 20 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 36 and 38 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from an experienced and established management team who ensure a clear ethos and values of the home that enables residents to receive good quality consistent care. A range of regular health and safety checks helps to promote the health and safety of residents and staff, however improvements need to be made to risk management in order to improve residents potential safety. EVIDENCE: The manager has many years relevant experience in managing and working with people who have mental health conditions. The manager is nurse qualified and holds the registered managers award. The deputy manager who is also a Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 21 provider is nurse qualified and has many years relevant experience and qualifications. Together they provide a strong sense of leadership and directions for the home. A sample of comments made about the manager included: “one of the best very good keeps being cheerful which I especially like, quite hardworking”; “very helpful”; “good manager seems to have everything under control” and “helpful and knowledgeable about residents” There are several mechanisms in place for the home to obtain feedback on the quality of the services provided and whether it is achieving its aims and objectives. This includes annual placement reviews with placement authorities, residents meetings, internal audits and feedback questionnaires. Although it was clear that there are systems in place to self assesses the homes services and facilities these had not been undertaken in over a year and the manager agreed to instigate them over the coming months. Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible persons external to the home. The manager stated that they do not manage the personal finances for any current residents. Written guidance is available on issues related to health and safety. Records submitted by the manager prior to the inspection stated that all of the necessary servicing and testing of health and safety equipment has been undertaken. Systems are in place to support fire safety, which include: regular fire alarms and emergency lighting checks, staff training and maintenance of fire equipment and fire drills were reported to have been undertaken. The manager reported that they have undertaken a fire risk assessment. This records significant findings and the actions taken to ensure adequate fire safety precautions in the home. The manager agreed to seek further advice on completing a fire risk assessment in order to keep updated in fire risk assessments completion. Not all radiators had been covered as required under the older peoples national minimum standards. The manager stated that the risks faced by exposed radiators to the current resident group was minimal and had therefore not fitted them, however this was not supported by a comprehensive risk assessment process. A residents consulted with said that they did not want their radiator covered. The manager has been required to assess the risks of unguarded radiators to establish whether guards need to be fitted in order to ensure residents safety. Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 22 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X 3 3 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 2 Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4)(c) Requirement That comprehensive written personal risk assessments are completed for all service users which are reviewed regularly and records the actions to manage identified risks. That unguarded radiators are risk assessed from the risk of accidental scolding in order to establish whether radiator guards or low temperature surfaces need to be fitted. Timescale for action 30/06/08 2 OP38 13(4)(c) 30/06/08 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 Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Woodbourne DS0000041738.V363262.R01.S.doc Version 5.2 Page 25 - 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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