Care Home: Woodhall Park

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What the care home does well Individual written needs assessments were in place before people were admitted to the Home so that their diverse needs were identified and planned for. Residents each had a plan of care which, together with their expressed comments, demonstrated that their health, personal and social care need were being well met. Residents were being treated with respect and their right to privacy was upheld. The Service provided activities that were diverse and benefited residents. Family contact was encouraged and residents were provided with meals that were varied and which they enjoyed. Procedures for handling complaints and abuse were in place ensuring residents were protected. The felt they were listened to. Residents were living in an attractive and comfortable environment that was clean and hygienic. The Service had a good level of well-trained staff to ensure that residents were safe and their needs were met. The Service was being well managed so that residents were protected and their best interests were promoted by the systems in place. Residents stated positive views about the Service. One said, in a postal survey, "I thank God every night that I am here". Another said, "I would thoroughly recommend the home to anyone". What has improved since the last inspection? A new manager has been in post for five weeks and has already prioritised monitoring of the Service through a series of quality audits in a number of areas. Improvements have been made to the safe handling of medicines. Recording practices are better and staff have completed training in the Mental Capacity Act so they are aware of the right of residents to make their own decisions and choices. Additional staff have been appointed to ensure that residents` needs are attended to promptly. Staff have been provided with training to increase their awareness of the abuse that residents may be exposed to. CARE HOMES FOR OLDER PEOPLE Woodhall Park Risley Hall Derby Road Risley Derby DE72 3SS Lead Inspector Tony Barker Unannounced Inspection 09:25 26th June 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 Woodhall Park DS0000002126.V368028.R03.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. Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodhall Park Address Risley Hall Derby Road Risley Derby DE72 3SS 0115 9490444 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) woodhall-park@btconnect.com Mrs Linda Isobel Ann Rowland Vacant Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one named service user under the age 65 for the duration of their care. 23rd January 2008 Date of last inspection Brief Description of the Service: Woodhall Park Care Home is situated in an appropriately adapted building, in a pleasant park setting in Risley, and is conveniently situated within easy reach of the M1 motorway and main Nottingham/Derby road. The Service is registered for the care of the 41 older people and admits service users with nursing needs. There are three lounge/quiet rooms and a separate dining area provided. There are two passenger lifts and staircase access to the first floor facilities. Thirty one of the bedrooms are single occupancy, with five double bedrooms provided for residents wishing to share. Five of the single bedrooms are equipped with en-suite facilities. A call system operates in all areas of the Home accessed by residents. Support services are in place with a choice of General Practitioners, and chiropody, dental, optician and other services arranged as appropriate. There is regular Activities Co-ordinator and physiotherapy input within the Service. The Service has open visiting arrangements. Woodhall Park DS0000002126.V368028.R03.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. The time spent on this inspection was 8.75 hours and was a key unannounced inspection. Survey forms were posted to service users, their relatives, staff and external professionals before this inspection and 16 people responded. The Acting Manager, the Activities Coordinator and a visiting pain relief nurse were spoken to. Several residents were spoken to - two in some detail. Records were inspected and there was a tour of the premises. Three residents were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire was reviewed prior to this inspection. The Service’s fees were detailed in individual service users’ contracts and ranged from £450 to £675 per week. Copies of the last inspection report from the Commission for Social Care Inspection (CSCI) were kept in the entrance hall. What the service does well: What has improved since the last inspection? Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 6 A new manager has been in post for five weeks and has already prioritised monitoring of the Service through a series of quality audits in a number of areas. Improvements have been made to the safe handling of medicines. Recording practices are better and staff have completed training in the Mental Capacity Act so they are aware of the right of residents to make their own decisions and choices. Additional staff have been appointed to ensure that residents’ needs are attended to promptly. Staff have been provided with training to increase their awareness of the abuse that residents may be exposed to. 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. Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 7 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 Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 8 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): 1,3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual written needs assessments were in place before people were admitted to the Home so that their diverse needs were identified and planned for. EVIDENCE: Copies of the Service’s Statement of Purpose and Service Users’ Guide were displayed in the entrance hall and were worded in a satisfactory manner and were up to date. These documents provided people with accurate information on which to base their choice of care home. One case tracked service user confirmed having a written Contract with the Service and a copy of the Service Users’ Guide. The files of three residents, all recently admitted, were examined. Preadmission written assessments of their needs were holistic in nature and included a ‘Map of Life’ and ‘Lifestyle Profile’. These two documents were person centred through addressing people’s preferences and ‘dreams’. For Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 9 example, people were asked what would be their dreams “if you could do anything?’ Based on these documents staff were in a position to identify individuals’ particular needs and preferences, and to meet them. All six residents who completed the postal surveys agreed that they receive the care and support they needed. One added that, “The care is excellent”. One case tracked resident told us that staff were “very caring…I can’t fault them’. The Service was not providing intermediate care. Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Unsafe practices regarding the administration of controlled drugs mean that residents were potentially at risk of harm. Residents were being treated with respect and their right to privacy was upheld. EVIDENCE: Three residents were case tracked so as to identify the standard of care provided by the service from their own perspective and from individual records and discussions with the Manager and staff. These three residents each had a written plan of care, drawn up by the Service, that recorded their needs and showed how these needs were to be met through a set of goals. Mostly, these recorded needs were related to individuals’ physical and health state rather than addressing their social and emotional needs - although, in other respects, care plans had improved since the previous inspection. Files showed that care plans were being reviewed monthly. These reviews provided an opportunity to monitor the care provided in order to reflect residents’ changing needs. All relatives, who responded to the postal survey confirmed that the Service met the needs of the resident. Also, staff surveys indicated that they received up Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 11 to date information about the needs of residents through care plans, diaries and daily hand-over meetings between shifts. Recorded risk assessments, and periodic reviews of these, provided further evidence of individuals’ on-going needs being monitored. These risk assessments covered areas such as residents’ risk from falling, moving and handling, tissue viability, and nutrition and provided a means of measuring and minimising these risks. Staff signatures and dates on the risk assessments ensured that the Acting Manager could maintain an accurate and up to date overview of care provided by the service. Residents’ health needs were being met directly by the Service and by appropriate contact with external health professionals. Evidence of this was from recording examined in the Home and from comments made by the health professionals and residents who completed survey questionnaires. One resident stated, “I receive the medical support I require and on time”. A number of improvements to the use of medicines were noted. Administered medication was being recorded accurately although one exception to this was found – in respect of one resident’s prescribed paracetamol. There was an inconsistency between the number of tablets recorded as having been administered and the number left in the container - the variable dose was not always being recorded to reflect the actual number of tablets given each time. The system of recording ‘as and when required’ medicines was examined and there was found to be no Protocol sheets in place to ensure that unsafe doses of medicine are not administered. Such sheets should make reference to the circumstances requiring administration of the ‘as and when required’ medication, the dose to be administered and the maximum dose over a 24hour period. Medicines were being appropriately disposed of when no longer needed or out of date. They were also being securely and appropriately stored. All those staff who administer medicines had received training in the Safe Handling of Medicines, the Acting Manager said, or were currently receiving this training. All but three new nursing staff had undertaken the ‘Introduction to Advanced Medicines Management’ training course. The Acting Manager was planning to further improve safe practices by training senior care assistants in the administration of prescribed creams. She discussed with us the audits and observations she was making to ensure that medication administration and recording errors were minimised. The Acting Manager had notified us of one error, regarding the administration of a controlled drug, during the five months since the previous inspection. We consider she had appropriately dealt with this matter. We were also notified of another error regarding a controlled drug five days after this inspection. The Home clearly needs to continue to closely monitor staff competencies in this area. Residents were observed being treated with respect by staff. Residents spoken to said staff respect their dignity and privacy and one said, “they do this very well”. Residents were observed to be well turned out and those spoken to confirmed that they were satisfied with the Service’s laundry system. Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 12 Residents had access to a telephone and one resident, who spent most of the day in bed, said “a phone is brought to me when my daughter rings”. All residents who responded to the postal survey confirmed that staff listen and act on what they say. Most felt that staff were usually available when needed though two referred to occasionally having to wait: “Sometimes I have to wait – due to staff attending other residents”. One resident spoken had also experienced the same problem, saying “I do have to wait when I call staff on the emergency bell”. When discussed with the Acting Manager she said that this concern had been raised at the last residents meeting. The minutes of this meeting were displayed in one lounge and the Acting Manager described policy changes that address staff availability. For instance, only one nurse makes notes on a shift now and makes these notes in a communal area. This was directly observed during this inspection. A large white board in the hall displayed the day, date and names and functions of staff on duty. One relative who responded to the postal survey expressed concern over male care staff supporting female residents with intimate personal care. The Acting Manager said she was aware of this concern and had immediately addressed it. A note of this resident’s preference for female care staff had been placed in the person’s care plan and the Acting Manager was planning to seek other residents’ views and wishes on this matter. Woodhall Park DS0000002126.V368028.R03.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service provided activities that were diverse and benefited residents. Family contact was encouraged and residents were provided with meals that were varied and which they enjoyed. EVIDENCE: Residents, in their completed survey questionnaires, were positive about the activities arranged by the Service. One stated that, “There are activities within the home and some that involve trips, all of which are good”. Another said, “I choose to stay in my room...the activities person visits each day”. The two residents spoken to confirmed they were stimulated by activities. One external health professional stated, in the postal survey, “The activity co-ordinator creates a lot of activity and stimulation…and the nurses try to organise a different care assistant each week to work with the physiotherapist to improve patient care”. Details of the future programme of activities were displayed in one lounge along with a calendar and a weather forecast. The Service’s Activity Co-ordinator gave a good account of her role and said she provides “something active…we have fun…I make residents think…I pamper them”. She gave examples of activities that meet individuals’ needs, though she accepted Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 14 that her recording of activities did not reflect the detail in this person centred approach. Residents spoken to said that they receive visitors who can stay for as long as they wish. One added that “visitors are able to come and go as they want to”. The visitors’ book confirmed that there were frequent visitors to the Home and evidence of this was observed during this inspection. Residents’ files examined confirmed good levels of communication with relatives. The Acting Manager said that six relatives attended the last relatives meeting. Relatives who responded to the postal survey all confirmed that they were kept up to date with important issues affecting the resident. One stated, “I was rung as soon as my mother needed to be admitted into hospital. This allowed me to be there in time to go in the ambulance with her”. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire indicated that 15 staff had completed training in the Mental Capacity Act. The Acting Manager said that this training was ongoing so that staff were made aware of the right of residents to make their own decisions and choices. The Acting Manager was aware of professional advocacy services such as that offered by Age Concern. She stated that no residents were currently in need of such professional advocates though one resident had a solicitor acting for them regarding personal finances. All other residents had good support from relatives. Residents spoken to, and others within the dining room, were all positive about the quality of food provided and the opportunity for alternative meals. One said “the food is excellent”. Another was pleased at being able to take both lunch and tea time meals in their bedroom. Menu boards were displayed in each half of the large dining room so residents did not have to ask for information about forthcoming meals. Residents who responded to the postal survey were generally positive about the quality of meals provided – with one commenting, “There is a very good and varied selection”. The lunch time meal on the day of the inspection looked appetising and it was noted that home-made soup was available to residents. A tour of the kitchen indicated satisfactory food stock levels. Woodhall Park DS0000002126.V368028.R03.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures for handling complaints and abuse were in place ensuring residents were protected. Residents felt they were listened to. EVIDENCE: The Service had a well-worded and up to date complaints policy that was displayed in the entrance hall. A Complements Folder was also available there. The Manager stated in the AQAA that no complaints had been received by the Service within the previous 12 months. This was confirmed by the Service’s Complaints Record where there were five entries dating back to 1993. Residents spoken to, and those who responded to the postal survey, knew who to speak to if they were not happy and how to make a complaint. One resident spoken to said that one concern they had had was “dealt with appropriately”. All staff had been provided with ‘safeguarding adults’ training that ensured they were fully aware of how to respond to evidence of abuse. The Acting Manager is looking to do a ‘Training for Managers’ course. One member of staff, in their postal survey, said residents “have a safe environment to live in”. A copy of Derbyshire’s Safeguarding Adults’ procedures was being kept within the Home. The Service’s own written policy/procedure on keeping residents safe was examined and found to be generally satisfactory. However, it included reference to what to do “if the abused person does not want contact made with Social Services”. This is an unsafe position for the Service to take and was discussed with the Acting Manager who agreed to remove this Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 16 reference. She said that the Service’s ‘Whistle Blowing’ policy is reinforced at one to one staff supervision sessions to ensure staff know they must raise any concerns they have about the safety of any resident. Risk assessments were in place for the use of all equipment that carries a risk of restraint, such as bed rails and wander mats, with associated signatures to indicate consent. These risk assessments had been modified, since the previous inspection, to take account of the capacity of each individual to consent in line with the Mental Capacity Act. Woodhall Park DS0000002126.V368028.R03.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were living in an attractive and comfortable environment that was clean and hygienic. EVIDENCE: A tour of the Home was undertaken and all areas were found to be well furnished and decorated. Corridors were fitted with handrails for the safety of residents with poor mobility. The majority of residents had a neck-hung emergency call button they could press to call staff in an emergency and all had access to alternative wall mounted call points. All bedrooms had been fitted with door locks since the previous inspection. There were records, with associated signatures to indicate consent, supporting the Acting Manager’s statement that residents had been asked if they wished to have a key for their door. Only one resident had chosen to have a key. Most bedrooms had lockable space inside and the Acting Manager spoke of plans to introduce these into all rooms. One shaft lift did not respond until the third press of the wall Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 18 button outside the lift on the first floor and its doors did not close until two presses of the button marked ‘ground floor’ inside the lift. We made the Acting Manager aware of this problem but she said it had not been experienced before. The domestic hot water at the wash hand basin in room 21 was exceedingly hot and there was no obvious sign of a thermostatic control valve fitted to ensure residents were not scalded. At the time of the inspection this room was unoccupied. One relative who responded to the postal survey said that “hoists and slings could be better designed”. The Acting Manager said she was aware of this person’s concern and intends to do an audit of hoists and slings as they are used with each individual resident. One large wheeled chair was found in each of two toilets so preventing access to that facility. These were immediately removed by the Acting Manager. The premises were clean and hygienic. Residents who responded to the postal survey confirmed that the Home was always fresh and clean. One added that, “The cleaners are excellent and always do a good job”. The AQAA indicated that 47 staff had completed Infection Control training and the Manager confirmed that two new staff were in the process of having this training. There was a notice in the entrance hall, above the signing in book, asking all visitors to wash their hands after entering the building and before leaving it. The Acting Manager said this was a new policy. Woodhall Park DS0000002126.V368028.R03.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): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inadequate staff recruitment practices meant that residents were potentially at risk. EVIDENCE: As already mentioned in Standard 10 of this Report some residents felt staff were not always available to meet their needs when wanted. The Acting Manager had made policy changes that address staff availability and she also spoke of additional staff being appointed to address this matter. These new staff comprise one full time and one part time member of care staff and one full time night care staff as well as one full time qualified nurse. It was noted from staffing rotas that, as at the previous inspection, some members of staff were working a high number of hours in a week: two were working 56 to 63 hours. However, we saw four ‘Working Time Regulations’ forms, signed by staff, that had been put in place since the previous inspection. The Acting Manager gave staff training and sickness as reasons for these excessive hours and pointed out that the new staff would ease matters. The AQAA showed that staff turnover was relatively low, with just four staff having left within the previous 12 months. The Manager confirmed that nine of the 23 care staff had achieved a National Vocational Qualification (NVQ) in Care at level 2. This was 39 and did not reach the 50 level required by the National Minimum Standards. The Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 20 Manager pointed out, however, that other care staff were currently undertaking this training and that within the next 12 months only six will be left untrained. Also, nine care staff were working towards their NVQ in Care at level 3. The files of two recently appointed members of staff were examined, including that of the Acting Manager. Safe recruitment practices were found to have been followed except that... • there was no proof of identity, including a recent photograph, on one staff file and, • the Service’s job application form did not explicitly ask the applicant for details of any unspent criminal offences or offences in respect of which they had been cautioned and, • there was no written verification of the reasons why one member of care staff had ceased to work in a previous position which involved contact with vulnerable adults and, • a 3.5 year gap in the employment history of this person had not been explained in writing. Criminal Records Bureau (CRB) checks and two written references were in place for both staff. However, a newly revised Staff Recruitment & Selection policy failed to refer to the need for written references. Staffing records confirmed that most staff had been provided with mandatory training to ensure adequate skills and competence for the job. One member of catering staff, and 30 of care/nursing staff, had still to receive training in safe food handling. There was an ‘at a glance’ training matrix available for a quick confirmation that this training had taken place. The Acting Manager said that, additionally, three staff had undertaken training on the topic of dementia with a further twelve to do in August 2008. There was evidence of good quality induction and foundation training of new staff and this met the specifications laid down by ‘Skills for Care’. One resident spoken to said, “I see good (staff) practice here…reflects good training, I think”. Woodhall Park DS0000002126.V368028.R03.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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service was being well managed so that residents were protected and their best interests were promoted by the systems in place. EVIDENCE: The Manager had 20 years of experience in nursing including six spent as a manager of a care home. She had been just five weeks in this present post and had made application to be registered as manager of Woodhall Park. She was approved as registered manager on 1st August 2008. She is fully qualified to undertake this post. One visiting health professional told us, “Staff morale has improved since Angela (the Acting Manager) has been here…they are working more effectively now…she is good at handling staff”. This person went on to say that protocols, Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 22 standards and the food were good. One member of staff who responded to the postal survey said, “Since the new manager has been in charge I have noticed a big difference…things are done straight away…everything is more organised and I don’t have any worries”. We noticed, at this inspection, a positive atmosphere within the Home. There was a generally high level of satisfaction of the Service from residents, relatives, staff and external professionals, as reflected in the completed postal surveys, and from speaking directly to residents. Residents meetings were being held and minutes of the last one indicated that residents’ views and wishes were being sought and taken account of by the Service. Relatives meetings were also taking place. The Acting Manager had initiated a number of audits of the Service including weekly drug audits of 10 residents and monthly audits of bed rails. Records of the monthly, monitoring visits to the Home, undertaken on behalf of the Registered Provider, were examined. These were of a good standard. It was reported that satisfaction surveys had been sent out to relatives, staff and residents in the past to gauge their opinion on the quality of the Service provided. However, as at the previous inspection, there was no documentation to show how the results of these had been used to improve quality within the Service. Also, there was no recorded evidence of a systematic cycle of planning, action and review - reflecting aims and outcomes for residents – by means of an Annual Development Plan for the Service. The Acting Manager spoke of plans to use the AQAA for this purpose. The completed AQAA contained clear and accurate information that was supported by evidence at this inspection. The systems for managing residents personal money were not assessed on this occasion. We understand that minimal money is kept on behalf of residents and this aspect of the Service was found to be satisfactory at the previous inspection. There was documentary evidence of all staff receiving one to one supervision sessions during June 2008, from the newly appointed Acting Manager. She spoke of plans to provide on going supervision every two months in order to ensure staff competence and development was being monitored and discussed. Most staff who responded to the postal survey confirmed they were given adequate support. One member of care staff who responded to the postal survey said, “We are supported very well by the matron and RGNs (qualified nurses)”. The AQAA showed that equipment was being checked and maintained appropriately. Weekly fire drills and fire alarm tests were being carried out. Good food hygiene practices were being followed. The Service had been given a 4 star Food Hygiene Rating by Erewash Borough Council. The Service’s monthly audit of accident records was examined. These indicated a higher incidence of residents falling in communal lounges than other in areas. This Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 23 analysis had led to nursing staff recording shift notes in a lounge area from where they could observe residents. Woodhall Park DS0000002126.V368028.R03.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 3 X 3 Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Timescale for action 01/08/08 2. OP9 13(2) 3. OP19 13(4)(a) 4. OP29 19(1)(b) and Schedule 2 Controlled drugs must be administered to individual residents according to the prescription to ensure they are not put at risk of harm. Staff competencies in the administration of controlled drugs must be closely monitored. An accurate record of medicines 01/08/08 given must be maintained to ensure that residents receive the doses of ‘as and when required’ medicines appropriate to their needs. Original timescale of 01/03/08 not met. Domestic hot water at taps used 01/08/08 by residents must not exceed 430C so as to ensure residents are not scalded. Risk assessments must be written to address this matter. Staff must not be employed to 01/08/08 work in the Service until all the required pre-employment checks stated in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001 have been obtained. This will ensure the safety of residents. DS0000002126.V368028.R03.S.doc Version 5.2 Woodhall Park Page 26 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. 3. 4. 5. 6. 7. 8. Refer to Standard OP7 OP12 OP9 OP10 OP12 OP18 OP19 OP28 OP29 Good Practice Recommendations There should be a plan of care for each resident stating how the Service is to meet their social needs. Protocol sheets, addressing the way ‘as and when required’ medicines are administered, should be in place. The Acting Manager should continue to monitor the issue of people waiting prolonged periods to be assisted to the toilet, in order to ensure their dignity is upheld. Records of activities that individual residents are involved in should reflect their stated needs and preferences as reflected in care plans. The Service should alert Social Services to any evidence or suspicion of abuse to a resident and its written policy/procedure should be reviewed to reflect this. Toilet areas should be kept clear of items that prevent access to these facilities. At least 50 of the care staff should achieve an NVQ in Care at level 2. The Service should amend its written Staff Recruitment & Selection policy, and its job application form, to ensure they reflect the nine paragraphs of Schedule 2 of the Care Homes Regulations 2001. The service should then work to this amended policy. All staff should receive training in safe food handling. The Service should undertake more self-monitoring through satisfaction questionnaires and the provision of an Annual Development Plan. 9. 10. OP30 OP33 Woodhall Park DS0000002126.V368028.R03.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Woodhall Park DS0000002126.V368028.R03.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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