Care Home: Woodham Grange

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What the care home does well There is a good admissions process so prospective service users know that their needs will be met at Woodham Grange. There are good complaints and safeguarding procedures in place, which protect people. The overall management of this service is very good. This has ensured that what we previously judged to be a poor service has significantly improved to the benefit of the people living here. What has improved since the last inspection? When we last visited there were lots of areas where the home needed to improve. The manager has worked very hard to address all of these issues as follows: Service users are now provided with a contract that includes more information about what they can expect from the service. Support plans have much improved and contain up-to-date information about how best to support service users with their health and personal care needs. The manager has contacted an advocacy service. This is so that those people who do not have close contact with their family will be supported to make decisions about their lives. There is a lot more for people to do and service users regularly take part in activities in the local community and further away. Mealtimes are a more pleasant occasion for people where everyone receives the support they need. Medication storage and records have improved. For example: the medication cupboard is now very clean and there is clear guidance for staff so that they know when to give people "as and when" required medication for people who have challenging behaviours. When we last visited the kitchen was dirty and untidy, the fridge handle was broken, there was lots of out of date food. The manager has sorted all of these issues out. There is also a new changing bed facility in the ground floor bathroom and aids have been provided in the ground floor toilet for people who may need them. Staffing levels have improved and the manager has completed a training needs analysis. This is important as it will help her to plan what training staff need.The management and organisation of the service has significantly improved which ensures the health, safety and welfare of the service users. What the care home could do better: There is very little for this service to improve on. However, we do recommend that the manager continue to develop the support plans and write on the medication record when and where "as and when" prescribed creams should be applied. We also suggest that staff be given training about pressure sores and dementia to help them understand the different needs of the service users. CARE HOME ADULTS 18-65 Woodham Grange Burn Lane Newton Aycliffe Durham DL5 4PJ Lead Inspector Nic Shaw Key Unannounced Inspection 11th August 2008 09:30 Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 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 Woodham Grange DS0000007523.V370575.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 Adults 18-65. 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. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodham Grange Address Burn Lane Newton Aycliffe Durham DL5 4PJ 01325 310493 P/F No E-mail Voyage.com Milbury Care Services Ltd 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) Deborah Elizabeth Saunders Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning disability - Code LD, maximum number of places: 8 The maximum number of service users who can be accommodated is: 8 18th February 2008 Date of last inspection Brief Description of the Service: Woodham Grange is a large two-storey property, situated in its own grounds. The home is in the Woodham area of Newton Aycliffe, within walking distance of the town centre and local amenities. The home is owned by Voyage. It is registered to provide care for up to eight adults who have learning disabilities, complex needs, and/or a physical disability. Everyone has their own bedroom and there is a spacious lounge/dining area and conservatory. Leading from the lounge is a spacious garden area that people can use in warmer weather. Woodham Grange is purpose built to accommodate people who use wheelchairs with wide corridors and a lift to the first floor. Woodham Grange DS0000007523.V370575.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 that the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken.” Before the visit: We looked at: • information we have received since the last full visits which were carried out in January and February 2008. • how the service has dealt with any complaints & concerns since the last visit • any changes to how the home is run • the views of other health care professionals . We did this by sending out surveys. Unfortunately none were sent back to us, however, we did speak to one health care professional, who regularly visits the home, over the telephone. The Visit: An unannounced visit was made on 11th August 2008. During the visit we: • talked with some of the staff and the manager • we were not able to interview people who live in this home as they all have complex communication needs. However, we did spend some time observing the care and support they receive. • looked at information about the people who use the service and how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills and training to meet the needs of the people they care for • looked around parts of the building to make sure it was clean, safe and comfortable • checked what improvements had been made since the last visit. We told the manager what we found at the end of the visit. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? When we last visited there were lots of areas where the home needed to improve. The manager has worked very hard to address all of these issues as follows: Service users are now provided with a contract that includes more information about what they can expect from the service. Support plans have much improved and contain up-to-date information about how best to support service users with their health and personal care needs. The manager has contacted an advocacy service. This is so that those people who do not have close contact with their family will be supported to make decisions about their lives. There is a lot more for people to do and service users regularly take part in activities in the local community and further away. Mealtimes are a more pleasant occasion for people where everyone receives the support they need. Medication storage and records have improved. For example: the medication cupboard is now very clean and there is clear guidance for staff so that they know when to give people “as and when” required medication for people who have challenging behaviours. When we last visited the kitchen was dirty and untidy, the fridge handle was broken, there was lots of out of date food. The manager has sorted all of these issues out. There is also a new changing bed facility in the ground floor bathroom and aids have been provided in the ground floor toilet for people who may need them. Staffing levels have improved and the manager has completed a training needs analysis. This is important as it will help her to plan what training staff need. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 7 The management and organisation of the service has significantly improved which ensures the health, safety and welfare of the service users. 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. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Good assessment processes ensure that potential service users needs can be met at Woodham Grange. Service users are provided with good information about what they can expect once they move into Woodham Grange. This ensures that their rights are protected. EVIDENCE: Each service user and their families have been provided with a residency contract. These have been up-dated to include information about the fees and who is responsible for paying these and the rights and responsibilities of both the service provider and service user. The manager has signed these and is in the process of obtaining the signature of each service user’s care manager. The service users who currently live in Woodham Grange have lived here for some time. Therefore, there have been no new admissions to the home since we last visited. The manager told us, however, that should there be a vacancy in the home then a full assessment would be obtained form the prospective service user’s social worker before their admission. She also told us that prospective service users and their relatives would be offered introductory visits as part of the admissions process. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9&10. Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Service users support plans have much improved and provide staff with good information about how their care needs can be met. Service users are now being supported to take risks and the staff continue to develop ways of supporting people to make choices in their daily lives. This enables the service users to lead independent lifestyles. EVIDENCE: Work has continued to introduce the new person centred planning format. Important information is available in plain language with pictures in the “getting to know me” document to help people understand them. All support plans now contain a manual handling assessment, people handling risk assessment and individual risk assessment. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 11 There is clear guidance available for staff in the support plans so that they know how best to support people with complex needs. Clear goals have been identified and the support plans focus upon the individual’s strengths and abilities. They are written in such a way as to ensure that service users are given as much control as possible over their lives. For example; there is a “dignity” plan for one person with the long term goal “to maintain dignity at all times”. Good step by step guidance was available in this, which staff were observed to follow in practise. This included encouraging the service user to take responsibility and control for their behaviour by being supported by staff to independently put back on their clothing. There was good evidence to show that care plans have been reviewed and updated to reflect the service users’ changing needs. For example: one person is at high risk of developing pressure sores and when this happens it is very important that staff support this person to spend time resting on special pressure relieving equipment. The support plan had been up-dated to reflect this. When we last visited we were told that one person “resisted” the care that they needed. However, this person’s support plan did not advise staff of the appropriate action they must take in such situations. We spoke to the manager about this who has since identified why this person “resisted” the care that they needed. This was because they did not want to spend time resting on their bed as the position they were being placed in was uncomfortable for them. After discussion with other health care professionals the manager has addressed this issue and this person was observed resting peacefully on their bed. Staff have had training in record keeping and the manager is currently looking at how to support staff to improve the quality of entries they make in the daily records. The manager is looking at ways in which service users can be helped to develop new skills and maintain existing ones. Service users are now encouraged to help around the house. When we visited one service user was encouraged to make themselves a cup of coffee after lunch. The people who live and Woodham Grange have complex communication needs. Information about each service user’s method of communication is included in their support plans. In order to support people with making decisions the manager has obtained the support of an advocate for each person who does not have regular contact or support from their family. For one service user it has been identified that they prefer to be supported with personal care by staff of the same genda. This has recorded in their support plan. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 12 Personal information about service users is now stored securely in the office. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16&17 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Opportunities for service users to take part in a range of activities both inside and outside the home have improved. And service users are assisted to maintain links with their families and to have a regular community presence. This enables them to lead a full and enjoyable life. Service users are provided with a nutritious, varied diet which helps to promote their general health and well being. EVIDENCE: The manager is in the process of developing a weekly activities timetable for each service user which will show what each person likes to do each day. This will be based upon information about their likes and interests. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 14 Activities recently enjoyed by service users include music concerts, such as Girls Aloud and Kylie Minogue, day trips to places of interest such as Whitby, Raby Castle and the Sea life Centre. Activities in the local community include walks into the town centre and the local park. The home has a mini bus and there are four drivers. The manager has taken steps to ensure that each service user has the opportunity of taking part in a trip out on the mini bus on a regular basis. The daily activity log, however, had not always been kept up to date. As previously mentioned the daily records are an area that the manager knows needs to improve. When we visited staff interacted with service users. Everyone sat together in the lounge and service users were fully included in the conversations that took place. The health care professional said that service users regularly go out now, they no longer sit around with little to do and that sometimes it was difficult catching people in. Staff said that as there were now more of them on duty each shift they were able to go out much more with the service users. None of the relatives were visiting on the day of the inspection. However, the manager told us that there are no restrictions on visiting times and that family and friends are encouraged to participate in daily opportunities (with the service user’s agreement). Since we last visited a nutrition assessment has been completed and nutritional recommendations implemented and included in the support plans. Risk assessments have been developed in relation to the support people need at mealtimes. For example one person is at risk of choking and as such it is necessary for their food to be blended. This information was recorded in their support plan, which is reviewed every three months. Although we did not sit through a meal, we observed part of the lunch time experience for service users and we talked to staff about whether they felt there had been any improvements in this area. Staff commented that, because service users now regularly go out, this means that lunchtime is a much more pleasant, quiet occasion for those people remaining in the home. This was the case on the day of the inspection where staff were able to provide those service users in the home with the support they needed in a sensitive, unrushed manner. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for meeting the personal and healthcare needs of people using the service have significantly improved. Service users now receive the support they need from staff to ensure that their personal, physical and emotional health needs are met. The service users are protected by the homes medication policies, procedures and practises. EVIDENCE: When we last visited we raised a number of concerns about the healthcare needs of the service users. In order to address these concerns the manager has worked closely with other health care professionals such as physiotherapists, occupational therapists and behaviour therapists, to review and up-date everyone’s support plan. The healthcare professional we spoke to said that there is now good communication with the home and that Kelly (the manager) is motivated and Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 16 makes sure that the advice they give is implemented, which previously was not the case. They said “anything we ask them to do they do”. There is guidance available so that staff know the most appropriate way to support those service users who may exhibit challenging behaviours. However, the approach we observed staff to use, although confirmed by the manager and other healthcare professionals to be appropriate, was not clearly recorded in the support plan. We talked to the manager about this who agreed to develop the support plan. A risk assessment tool is used to assess if a person is at risk of developing a pressure sore. For one service user at risk of developing pressure sores, as previously mentioned, a detailed support plan is in place, which includes positional changes every 15 minutes. Although staff confirmed that this took place, no records of this are maintained. The district nurse visits this person regularly each week to monitor the condition of the pressure sores and to offer advice and guidance for staff. It was good to note that staff have an awareness of dementia and the impact of this upon people with learning disabilities. As a result of this one service user has recently been diagnosed with dementia. Their support plan review with their care manager, has been brought forward to ensure that their needs continue to be met at Woodham Grange. The medication cabinet was clean and well organised. The manager has introduced a weekly audit of medication which includes cleaning the cabinet. External and internal medication is stored separately, which is good practise. The manager has obtained an up-to-date medication reference book and staff monitor the temperature of the office to make sure that medication is stored securely. Detailed medication plans are in place for those people who need “as and when” medication for challenging behaviours, which has been agreed and signed by the GP. Some people have been prescribed creams which are to be administered “as and when required”. However, there was no information on the medication administration record to inform staff of when and where such creams are to be used. Senior staff administer medication. Before they are able to do so they undergo training provided by the organisation, to ensure their competency. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Whilst service users communication skills are very limited, arrangements are in place through the complaints process to promote their safety and offer protection. Appropriate policies and procedures are in place, supported by staff training, which ensure that service users are protected from abuse and neglect. EVIDENCE: The home’s complaints procedure provides staff with guidance about how to complain. There is an easy read version available for service users called “let us know what you think”. The manager told us in the information we asked for before the inspection that there have been no complaints in the last six months. Recently the manager has provided relatives and care managers with a copy of the “let us know what you think” leaflet and the organisation’s protection of vulnerable adults policy. The home’s safeguarding policy provides staff with guidance about how to handle adult protection concerns. There have been no safeguarding concerns raised since we last visited in February 2008. All staff have been provided with training in the protection of vulnerable adults as part of their induction. They have also been provided with training called “non crisis intervention” so that Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 18 they know the best way to support people when they are displaying challenging behaviours. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,29&30 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. The environment has much improved providing the service users with a safe place to live EVIDENCE: The building throughout was found to be clean with no unpleasant odours. There is a communal lounge/ dining area with a spacious conservatory area. These are bright, airy, comfortable places, providing service users with plenty of space to spend their time. There is also a well maintained spacious garden which everyone can safely use. All rooms are single occupancy and service users are encouraged to personalise these areas. Aids and adaptations are provided to meet the different physical needs of the service users. This includes a new changing bed facility in the ground floor bathroom and a new bedside rail cover for one person’s bed. A new wardrobe has been purchased for one service user. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 20 The staff are responsible for domestic tasks. A cleaning rota has been introduced. Staff follow this to ensure that communal and kitchen areas are kept clean at all times. They sign a record as evidence of this. When we last visited the kitchen was particularly dirty. There was out of date food in the cupboards and the fridge handle was broken. The manager has addressed all of these issues. The woodwork on communal doors needs to be repainted. The manager knows about this and has taken steps to ensure that this and the carpet in communal areas, (which is badly marked), are addressed this year. Detailed policies and procedures are available in relation to infection control. Staff have been provided with training in relation to this. Protective gloves and aprons are available for staff to use. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35&36 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from skilled, experienced staff and the good staffing levels ensure that the service users needs are readily met. Service users are supported and protected by the home’s recruitment practices. EVIDENCE: On duty on the day of the inspection were five staff, including the manager. As previously mentioned staff said that staffing levels were much improved and this meant that service users could regularly go out. They also commented that morale was much better in the home. The healthcare professional said that now, when she visited the home, “the staff approach is totally different, we used to get the cold shoulder”. The organisation provides staff with opportunities to go on a wide range of training beyond the basic requirements. The staff training files are well organised. They contain evidence of the training staff have completed Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 22 together with a signed copy of their job description. There is a training needs analysis to help the manager identify and plan future training needs. In addition to mandatory training, such as food hygiene and fire safety, this has included training in specialist area such as person centred planning awareness, epilepsy training, and introduction to learning disabilities. There is a training programme and plans are in place for some of the staff to receive training in the Mental Capacity Act and its code of practise. However, staff have not received training about pressure sores or dementia, which would be beneficial given the diverse needs of the service users. All staff have been given a copy of the General Social Care Council code of practise and they are receiving regular supervisions with the manager. All staff we met were clear of their roles and responsibilities. They were very knowledgeable of the needs of the service users and could describe in detail each individual’s health and personal care needs. We looked at a sample of staff recruitment records. These showed that an Enhanced Criminal Records Bureau (CRB) check is obtained as well making sure the Protection of Vulnerable Adults (POVA) list is checked. In addition to this appropriate references and full employment histories are obtained, before prospective employees can work in the home. Sometimes new staff work in the home with a POVA check only. The manager makes sure that they do not work unsupervised whilst waiting for their CRB clearance check. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41&42 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Overall management systems have significantly improved and ensure that the health, safety and welfare of service users are promoted. EVIDENCE: The registered manager has been on long term sick leave. In her absence an experienced manager from another service has been managing the home. She has extensive experience of working in care and 5 years experience of managing a care home. She has achieved the NVQ level 4 qualification in care and also has the Registered Managers Award. Other training the manager has undertaken, to keep her knowledge and skills up-to-date, includes training about the Mental Capacity Act, risk assessment and epilepsy training. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 24 Within the short time she has been managing the service there have been significant improvements in the standard of care provided and consequently “outcomes” for service users. The healthcare professional said “the home has improved in all aspects”. She said that the service is much more organised and that the manager will contact them for advice, which previously did not happen. Another person who works for the Local Authority had taken time to write to the manager thanking her for her hard work in improving this service. There have been monthly reviews of the service carried out by the home’s line manager. After each visit a detailed report is completed and given to the manager. This includes an action plan specifying any outstanding areas which need to improve with timescales attached. The manager commented that in the last six months she found the support from her line manager to be invaluable. Personal evacuation procedures have been completed. These provide staff with detailed guidance about what to do should there be a fire. All staff, including nightstaff, receive regular fire instructions. The manager is also in the process of purchasing a magnetic devise to hold the kitchen door open, so that people can easily enter this area. Such a devise automatically closes in the event of a fire. The manager has also made sure that staff do not keep their cigarettes in the laundry area. The manager has carried out risk assessments for service users personal money management skills. She has also obtained a copy of the Mental Capacity Act to raise staff and their awareness of the implications of this. Woodham Grange DS0000007523.V370575.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 Adults 18-65 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X 3 3 x Woodham Grange DS0000007523.V370575.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. 1. Refer to Standard YA19 Good Practice Recommendations It is recommended that the support plans continue to develop. For example; Staff should maintain a record of the positional turns staff carry out with the service user who has a pressure sore. There should be more detail is one person’s support plan about the action staff should take when they display challenging behaviours. Staff should ensure the daily logs are completed in full, including the activities they have been involved with. Such actions will help to ensure the health and welfare of service users is protected. Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 27 2. YA20 It is recommended that details of “as and when” prescribed creams be recorded on the medication administration record. This is to make sure that people receive this medication when they need it. It is recommended that staff receive training in relation to pressure sores and dementia. This will help them to fully understand the diverse needs of the service users. 3 YA35 Woodham Grange DS0000007523.V370575.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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