Care Home: Woodland Care Home

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What the care home does well What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE Woodland Care Home 189 Woodland Road Hellesdon Norwich Norfolk NR6 5RQ Lead Inspector Mr Jerry Crehan Unannounced Inspection 17th January 2008 09:50 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 Woodland Care Home DS0000044375.V358540.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. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Care Home Address 189 Woodland Road Hellesdon Norwich Norfolk NR6 5RQ 01603 787821 01603 403874 woodland@schealthcare.co.uk www.schealthcare.co.uk Southern Cross 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) Application Pending Care Home With Nursing 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Forty-six (46) Older People may be accommodated. Date of last inspection 5th June 2007 Brief Description of the Service: Woodland Nursing Home is situated in the residential area of Hellesdon. Purpose built in 1990 the home has ground and first floors comprising primarily single room accommodation (most with en-suite facilities), with some double room accommodation. There are four communal lounges, which are within easy access of resident’s own rooms. The home also offers a range of adaptations and aids to promote mobility and independence. The grounds are accessible by wheelchair users and there are car-parking facilities to the front and side of the premises. The range of weekly fees is £333 - £601. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. This report gives a brief overview of the service and current judgements for each outcome group. Before the inspection the manager of the service completed a lengthy questionnaire about the service. Eight comment cards were received from relatives of people who use the service; one comment card was received from staff that work at the service. A recommendation has been made in this report that the manager find alternative means to promote and support residents in the completion of survey comment cards prior to inspection visits, as none were received from the service despite cards for every resident having been provided. The comment cards that were received from relatives reflected positive views about recent improvements the home, its management and the care provided by staff. Records held by the Commission and previous inspection reports were checked. This key inspection compromised an unannounced visit to the home that took place over 8 hours on 17th January 2008. Opportunity was taken to tour the premises, look at care records and policies, and communicate with residents, care staff, nursing staff and the manager. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. What the service does well: • • • An assessment is carried out of all prospective people to use the service, who are invited to the home with their relatives. People who use service receive good nursing and personal care that is based on their individual needs and set out in their individual care plan. Care delivery observed during the inspection visit was good. Care and nursing staff interaction with residents was professional and courteous with all staff taking their time to assist residents. The home is safe, clean, tidy and well maintained throughout. Domestic staff, like other staff, were observed to be hard working. Social and recreational activities meet individual’s expectations throughout the home, and provide a link with the community. • • Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 6 • The manager and proprietor have developed good systems that help to ensure that the home is run in the best interests of residents, they include seeking the views of residents and others associated with the home. Finding an alternative means to promote and support residents in the completion of inspection survey comment cards has been recommended. The manager is actively engaged in managing the home and seeking to improve services. • What has improved since the last inspection? • The service provides new and prospective people who use the service with sufficient and up to date information about the home to make an informed choice about long-term care, and about how to make a complaint. There are improvements to the garden areas, which may be more evident in summer months. A gazebo has been erected in the garden and some new robust looking garden furniture obtained. Call bell systems have been introduced to the communal areas within the home, in addition to those already in place in residents’ bedroom accommodation. Since the last inspection visit all individual bedroom accommodation has been fitted with locks in order that residents can lock their bedrooms if they wish to support their privacy and the security of their belongings. There have been improvements to the induction and ongoing training (in particular the protection of vulnerable adults) available to staff and a generally more organised approach to training. The new management situation at the home has improved the morale of the staff group and the responses of residents’ relatives in their comment cards received prior to the inspection visit. • • • • • Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 7 What they could do better: • It is recommended in the report that social and life history work continue to be carried out by care staff at the home as this contributes to improving the care for residents as individuals. There is limited assistance available for care and otherwise attending to residents during the late afternoon and evening. Staff training recommendations have been made concerning training validation evidence, NVQ training, infection control and training for nursing staff in conducting staff supervision. • • 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. Woodland Care Home DS0000044375.V358540.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 Woodland Care Home DS0000044375.V358540.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): Standards 1 & 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people to use the service have their needs assessed, and access to all of the information they need about the service they may choose. EVIDENCE: The home now has an updated ‘Statement of Purpose’ and ‘Service Users Guide’ to reflect the services provided at the home since the change of ownership in 2007. These documents contain sufficient information for anyone to make an informed choice about long-term care. The Service Users Guide contains a summary of the home’s complaints procedure and is available along with the Statement of Purpose in the foyer of the home and in every resident’s room. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 10 The home has a well-designed assessment pro-forma (pre-admission assessment) used by the manager or deputy manager when collecting information to ascertain the level of support required by prospective residents. There is evidence of assessment for prospective residents seen in their files, and the manager stated that he or the deputy manager always seek to visit prospective residents in their accommodation prior to admission. Woodland Care Home DS0000044375.V358540.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): Standards 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services receive good health and personal care that is based on their individual needs. Medication practices safeguard the health and welfare of people who use the service. EVIDENCE: A sample of residents care files containing individual care plans was reviewed. All the care plans were well detailed regarding the resident’s nursing, personal, physical, social and mental health care needs. Each of the plans seen includes a range of risk assessments of individual care needs, such as mobility, continence, falls, nutritional needs and other health matters such as tissue viability and risks from pressure areas. Sample care plans seen included information for care staff about residents’ self-caring abilities and where help is required. This kind of clarity helps residents to maintain areas of independence. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 12 There was limited information in care files as to residents social or life history. This information makes an important contribution toward assisting care staff to build a relationship with residents as individuals. The manager explained that work is in progress to undertake comprehensive life story work with each resident and that he has documents in place that staff will complete with residents and their relatives. It is recommended that social and life history work continue to be carried out by care staff at the home as this contributes to improving the care for residents as individuals (See Recommendations). Each care plan seen has recently been reviewed, and some review records provided evidence of resident and family involvement in indicating their needs and preferred care. Care delivery observed during the inspection visit was good. Carers’ interaction with residents was professional and courteous with care staff taking their time to assist residents. Carers assisting a resident in a transfer from a wheelchair to an armchair managed the transfer well, though did not explain to the resident what they were going to do before undertaking to assist in the transfer. This would have helped the resident anticipate what was to happen, and can result in safer and more satisfactory transfers for people. A nurse was observed carrying out care for two residents at lunchtime in assisting them to eat their meal. The care was carried out well reflecting the differing needs of each resident being supported to eat, and the nurse maintained a supportive discourse with the residents throughout the process. A group of residents spoken with in one of the home’s communal lounges said that they were very happy with the care and the nursing care provided by staff at the home, none indicating that they had any complaints. Evidence of specialist services such as chiropody, hearing and dental services were regularly sought for those who required these. The manager indicated that residents are registered with two separate doctors surgeries, and if new residents wish to retain their G.P when moving to the home they will be supported to do so if their G.P’s Practice policy permits. One of the trained nurses on duty administers medication the home. The medication records were checked for several residents and were found to be satisfactory. There were no residents responsible for their own medication at the time of the inspection visit. Staff receive training with regard to medication and are familiar with the home’s policy and procedure. There are suitable safe storage arrangements for medication in a dedicated room that is temperature controlled. The home uses a ‘Monitored Dosage System’ for administration of most medicines. There were resident-identifying photographs alongside medication administration charts to assist in the safe administration of medicines. Appropriate records are kept for the receipt of medication into the home, its administration and any medication to be disposed of. Audits are undertaken of medication and medication records ‘mid cycle’ by the deputy manager – audit records were seen. This process adds a further degree of safety to the management and administration of medication at the home. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 13 Residents spoken with said that nursing and care staff listen to them and treat them with respect. Residents were also clear that their right to privacy is respected at the home, and that their visitors are made welcome and can be seen in private if they wish. This was in evidence throughout the inspection visit. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 14 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services have access to a good diet and meals that are well prepared. Social and recreational activities are on offer at the home and sufficiently varied meet individual’s needs and expectations. EVIDENCE: The home’s activities programme is developing and becoming more varied since the appointment of a dedicated activities coordinator who has been in a part time post since June 2007. A group of residents were observed participating in a game of Bingo during the morning. Residents spoken with stated that there are activities on offer to choose from. One resident said that they had regularly been taken to see Norwich City football matches. A monthly programme of activities is produced which include communal activities such as bingo, a safe darts game and arts and crafts but also include one to one activities with residents who prefer this, or whose needs make it difficult for them to join in other activities. The home produces a regular newsletter for residents and their relatives. The newsletter advertises the activities programme and other activities and entertainments taking place at Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 15 the home. Recent events at the home have included a dolls exhibition and a Christmas party where the Salvation Army visited the home and gave a musical performance to residents. Some residents participate in activities outside of the home. A resident said that they attend a local jazz club and a group of residents attended a party at the Hellesdon Community centre at Christmas. Residents confirmed that their relatives and other visitors could attend the home at any time. There were numerous visitors to the home at the time of the inspection visit. Resident’s bedrooms seen on the day of the inspection visit are all well furnished and equipped to suit people’s daily lifestyle and reflect their personal choices and preferences. Bedrooms have been decorated to a good standard with a mixture of colour to promote a greater sense of individuality and interest to the environment generally. Advocates are in place for some residents who require someone to represent their interests. The manager stated that information about the advocacy (and other) services provided by Age Concern are given to residents who need advocacy support. Since the last inspection of the home the menus and meal planning processes have been under review with the proprietor’s ‘Nutmeg’ catering system being introduced. This offers a range of designed menus that are nutritionally balanced and provide additional information about recipes, costs and what produce needs to be purchased. The system had been adapted by the chef and manager to suit the needs of the home given their experience of the preferences of residents. The chef is provided with up to date information by care staff as to residents likes and dislikes in addition to other dietary information such as diabetic diets and softened diets. The main meal on offer on the day of the inspection was turkey and ham pie with cauliflower, green beans, swede mashed potato and gravy. There was an alternative option of sliced pork. Sweet was pear crumble and custard or fresh fruit salad. The meal looked appetising and was well presented. Residents observed during the visit evidently enjoyed their lunch, and those asked about the meals on offer were complimentary about their quality. Residents have access to food and drinks during the day if needed. A resident was eating a peeled orange and drinking tea mid morning with others. The kitchen was clean, tidy and benefiting from extra space, as alternative storage for dry and frozen goods has been established. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 16 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): Standards 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements for responding to the concerns and complaints of people who use the service are good. People who use the service are protected from abuse because the manager and staff have a good understanding of safeguarding vulnerable adults. EVIDENCE: The manager keeps a record of all complaints. The manager has dealt with two complaints since the previous inspection. Both of these indicate what action was taken by the manager to investigate the complaint and the complaint outcome. The home has a detailed complaints procedure and information on how to make complaints is detailed in the home’s guide for residents. Residents spoken with during the inspection visit stated that they would speak with the nurses or carers if they had a concern or complaint. The home has an adult protection policy in place; this is discussed with staff when they commence employment. Staff have a basic understanding of ‘whistle blowing’, and various forms of abuse. The manager had arranged for the majority staff to undertake ‘Protection of Vulnerable Adults’ (POVA) training with further training on offer. The training programme was detailed, including identification of what abuse is, different kinds of abuse, the role of Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 17 the carer in dealing with reported or witnessed abuse, and defining a vulnerable adult. Records of this training was seen. It is recommended that evidence of learning and validation be kept in individual staff training files (See Recommendations). Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 18 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): Standards 19, 22, 24 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment at the home is safe, well presented and maintained to support the needs of people who use the service. EVIDENCE: The home’s environment was safe, very clean, tidy and well maintained throughout. There is a large well presented reception area that contains information relevant to the service, including the home’s Statement of Purpose, Service User Guide, a copy of the home’s most recent inspection report and photographs of the staff team. The team of domestic staff were observed to be effective and hard working. People’s bedroom accommodation is personalised and reasonably decorated, as are communal areas. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 19 There were some improvements to the garden areas, which may be more evident (and beneficial) in summer months. A gazebo has been erected in the garden and some new robust looking garden furniture obtained. The manager stated that he has plans to advertise to some spare maintenance hours specifically to maintain and improve the gardens. Pathways around the home have been cleared to enable safe and easy access in an emergency. The homes windows were being cleaned on the day of the inspection visit. Since the last inspection visit to the home call bell systems have been introduced to the communal areas within the home, in addition to those already in place in residents bedroom accommodation. Pendant type call bells were available and the manager said he is planning to provide pull cord type also, as these are more suited to some people’s needs. A variety of hoists and other aids are available at the home to meet the assessed needs of residents. These were suitably stored when not in use. Since the last inspection visit all individual bedroom accommodation has been fitted with locks in order that residents can lock their bedrooms if they wish to support their privacy and the security of their belongings. The manager stated that there is an ongoing programme to ensure that all residents have a lockable storage facility in their bedrooms also. A single lapse in good infection control practices was noted as a carer dealt with dirty laundry without wearing gloves and then assisted a resident with a move to a chair in a lounge area, without having washed their hands. This was brought to the manager’s attention during the visit. Disposable gloves were evidently available to all staff, who were otherwise seen to be using them when required. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are adequately trained and skilled. However, they are not consistently deployed in sufficient numbers to support the specialist needs of people who use the service. EVIDENCE: There were 37 residents accommodated at the home at the time of the visit. There is a total care staff compliment of 17 care staff in addition to the nursing staff and the manager. At the time of the inspection there were five care staff and two nursing staff working during the morning and early afternoon, and four care staff and two nursing staff working the afternoon/evening shift. There are three carers and one nurse on duty at night. The numbers of care staff working at the home during the afternoon is not adequate to meet the needs of its very dependent residents. Residents need significant levels of assistance in the afternoon as well as the morning, such as two people to assist with their transfers, two people to assist with hoisting, and support at mealtimes to eat ensuring they are not rushed. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 21 Nursing staff have residents nursing needs and medication administration to attend to during the afternoon. As the senior person’s on duty they have a responsibility to deal with the supervision of care staff on the floor, to deal with visitors to the home including health professionals and residents relatives or friends, and from approximately 5.30pm nurses and care staff are required to answer the telephone. There are rarely organised activities during the afternoon as the activities coordinator works part time. This combination of factors means that there is limited assistance available in carrying out personal care and otherwise attending to residents during the late afternoon and evening (See Requirement 1). The difficulty may be overcome through a different approach to staff deployment, or through the provision of an additional ‘twilight’ carer. Seven of the seventeen care staff have a qualification at NVQ 2 or NVQ 3, a further two staff are currently undertaking the training. The home currently falls below the recommended numbers of staff who have undertaken the NVQ 2 training, however, the successful completion by the staff currently undertaking the training will see the service exceed the minimum recommended numbers. It is recommended that the manager encourage care staff to undertake this training and update their skills (See recommendations). Sample staff files provided evidence that residents are protected by good recruitment practices. The home has acted on a recommendation made at the last inspection visit that staff files be reviewed ‘filleted’ and brought up to date. Care staff spoken with indicated that they had access to appropriate induction training when newly employed, and the opportunity to work in a supernumerary capacity observing experienced carers. Staff who have undertaken the home’s induction training programme will have had access to suitable infection control training, those staff who have not yet had this training will be trained within a rolling cycle of training provided by the proprietor. It is recommended that all staff receive infection control training at the earliest opportunity (See Recommendations). Staff have accessed a variety of appropriate mandatory training, including manual handling, health and safety, first aid, medication and adult protection training – including refresher training for staff in adult protection as required at the last inspection (see recommendation above). The manager indicated that staff are aware of the home’s fire procedures and that there are monthly drills. He added that he is in the process of obtaining further fire awareness training for staff at the home. The manager also indicated that he intends to take an active role in ensuring that continuing training and refresher training is available to nursing staff in a range of clinical areas such as wound care, catheter care, ‘PEG’ feeding and diabetes care. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 36, 37 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home promotes the health and care of people who use the service. The service has improved because the manager shows he is committed to providing good quality care and nursing. EVIDENCE: The new manager is a qualified ‘Registered Mental Nurse’ and has been in post for over two months. He has approximately one year’s management experience in nursing/care services with a background of approximately 10 years in nursing and care services for older people and people with a disability. He has registered to undertake the ‘Registered Managers Award’ and has begun the process of applying for registration with the Commission. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 23 The deputy manager is also a qualified nurse. She works as a manager to deputise for him. When manager is at the home the deputy’s role is a mix of nursing and management. There is an on-call system at weekends when nursing staff are in charge of the home. The system provides access to the manager or deputy, and to an area on call support system operated by the proprietor. Staff expressed positive views about the new manager, indicating their appreciation that he ‘does not stay in the office’ and that he is ‘approachable’. The manager and proprietor have developed systems to ensure that the home is run in the best interests of residents. These include surveys of the views of residents and others associated with the home, copies of which are available in the home. There are staff team meetings, residents and relatives meetings, and various audits and validation audits undertaken by the proprietor’s representatives. There is a regular newsletter produced by the home that keeps people informed of past and future events and other information. It is recommended that the manager find alternative means to promote and support residents in the completion of survey comment cards prior to inspection visits, as none were received from the service despite cards for every resident having been provided (See Recommendations). Relatives or appointees manage most resident’s financial affairs. Financial records reviewed were satisfactory and are evidently audited periodically for the protection of residents and staff. Nursing staff attend formal supervision with the manager or the deputy manager with the relevant records contained within the staff files. Nursing staff provide formal supervision care staff. It is recommended that nursing staff required to provide formal supervision are offered training in how it should be carried out, if they have not already (See Recommendations). The confidentiality and privacy of residents is supported at the home, and has improved with some of the recent environmental changes that have taken place. The home demonstrates generally good practices ensuring residents health, safety and welfare. Relevant training for staff, including moving and handling, medication, first aid and good records support practices. An infection control training recommendation has been made, and the manager is arranging fire awareness training for those staff who need it. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 2 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 3 2 Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 25 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 OP27 Regulation 18(1)(a) Requirement The registered person must ensure that staff are deployed and working in such numbers as are appropriate for the health and welfare of residents. Timescale for action 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that social and life history work continue to be carried out by care staff at the home as this contributes to improving the care for residents as individuals. It is recommended that evidence of learning and validation be kept in individual staff training files. It is recommended that the manager encourage care staff to undertake NVQ training and update their skills. It is recommended that all staff receive infection control training at the earliest opportunity. It is recommended that the manager find alternative means to promote and support residents in the completion of survey comment cards prior to inspection visits, as none DS0000044375.V358540.R01.S.doc Version 5.2 Page 26 2. 3. 4. 5. OP18 OP28 OP30 OP33 Woodland Care Home 6. OP36 were received from the service despite cards for every resident having been provided. It is recommended that nursing staff required to provide formal supervision are offered training in how it should be carried out, if they have not already. Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Woodland Care Home DS0000044375.V358540.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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