Care Home: Woodland Grove

Similar services:

• Fairfields Country Rest Home
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home
• Belma
• Hunters Care Centre
• Manor Lodge

What has improved since the last inspection? There was one requirement and a number of recommendations and it is evident that the home has responded to the requirement. Staff now receive regular support and supervision with a line manager. Whilst there have been some improvements in records relating to prescribed medication and a homely remedy policy now in place. Staff still need to discuss with the GP when it is appropriate to offer individuals over the counter medication in line with the home`s homely remedy policy. What the care home could do better: Individuals should be assured that the information describing the service is up to date to enable them to make an informed choice about whether to live at Woodland Grove. Individuals must be assured that individuals that wander into bedrooms safeguards are in place. Individuals should be assured that medication for mild pain relief is in place. Fire safety could be improved if night staff participate in regular fire drills as advised by the local fire officer.Woodland GroveDS0000008163.V374755.R01.S.docVersion 5.2Page 7 Key inspection report CARE HOMES FOR OLDER PEOPLE Woodland Grove Weston Park Bath Bath & N E Somerset BA1 4AS Lead Inspector Paula Cordell Unannounced Inspection 7th April 2009 10:00 DS0000008163.V374755.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Grove Address Weston Park Bath Bath & N E Somerset BA1 4AS 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) 01225 464004 01225 426501 tina.davis@anchor.org.uk keri.sherwood@anchor.org.uk Anchor Trust Manager post vacant Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Woodland Grove DS0000008163.V374755.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 either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 50. 16th May 2007 Date of last inspection Brief Description of the Service: Woodland Grove is a care home for older people owned and managed by Anchor Trust Foundation and provides accommodation for up to 50 people whose primary care needs fall within the category of old age. The home is a converted older property, which has been extended and adapted to provide residential care within individual flats. Each flat has a bed sitting room, small-integrated kitchen and en-suite bath or shower, basin and toilet. There is a large communal lounge, which can be divided into two rooms and a dining room with direct access to the patio seating area. There is lift access to all parts of the home. The home is set in extensive gardens and located in the Weston area of Bath within easy reach of the town centre and local amenities. Fees are £625 and £725 per week inclusive of all care and facilities in individual’s flats, not including community health services. Woodland Grove DS0000008163.V374755.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 stars. This means the people who use this service experience good quality outcomes. This was an unannounced visit as part of a key inspection process. The purpose of the visit was to review the requirements and recommendations from the visit in May 2007 and to monitor the quality of the care to the individuals living at Woodland Grove. The Care Quality Commission has not received any formal complaints. However, there was a short embargo placed on the home by Bath and North East Somerset due to concerns relating to the management of the home and in particular some discrepancies in how the home was covering the costs of the fees from some of the individuals. This was fully investigated by Anchor Trust and consequently there have been some changes in the management of the home. Anchor Trust has kept both the local authority and the Care Quality Commission informed throughout the process. The temporary embargo has been lifted by Bath and North East Somerset. The inspection was planned using correspondence received between May 2007 and this visit. This included letters, regulation 37 notifications, and surveys from people who use the service (13), professionals (5) and staff (3). The home forwarded their annual quality assurance assessment when asked and this gave us lots of information about how the service was doing, where they needed to improve and some statistical data. An Annual Service Review was completed in May 2008 by the Commission for Social Care Inspection (now called the Care Quality Commission). This evidenced that the home continued to provide a good quality service to the individuals living at Woodland Grove. The visit was conducted over seven hours. During which a tour of the home was conducted this gave an opportunity to speak with people who use the service, visiting relatives, staff and general observations. These assisted in forming a judgement on what it was like to live at Woodland Grove. Records were viewed during the visit relating to the running of a care home including care records, staff recruitment and health and safety. Feedback was given at the end of the visit to the deputy manager and a support manager from another home. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 6 What the service does well: There is a real effort on the part of the management and the staff to provide a homely, supportive environment where individuals have their needs met yet are able to retain their independence as far as possible. People who live in the home are given opportunity to voice their views and an open, friendly and welcoming environment has been created. There is a commitment to providing individuals with meaningful activities and these are arranged on a daily basis with both group and one to one activities being organised. Activities are organised both in the home, the community and by inviting people into the home. Individuals spoken with during this visit clearly liked living in Woodland Grove and felt safe. What has improved since the last inspection? What they could do better: Individuals should be assured that the information describing the service is up to date to enable them to make an informed choice about whether to live at Woodland Grove. Individuals must be assured that individuals that wander into bedrooms safeguards are in place. Individuals should be assured that medication for mild pain relief is in place. Fire safety could be improved if night staff participate in regular fire drills as advised by the local fire officer. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Woodland Grove DS0000008163.V374755.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 Grove DS0000008163.V374755.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Individuals have sufficient information to enable them to make a decision on whether to move to Woodland Grove. Individuals can be confident that Woodland Grove can meet their assessed care needs due to the thorough assessment that is completed prior to them moving to the home. EVIDENCE: The home has a statement of purpose and a service user guide. However, this needs to be reviewed in light of the new manager being appointed and the number of people the home can support. The statement of purpose states that the home can support 46 individuals this is incorrect as the home increased the occupancy to 50 last year. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 10 There was good documentation in place to demonstrate that a thorough assessment is conducted by the home to ensure the needs of the individuals can be met. The assessment covered all the areas identified in the National Minimum Standards. It was evident that the home obtains a copy of the placing authority’s assessment and care plan which along with the home’s assessment informs the care planning processes adopted by the home. Individuals and their relatives are encouraged to visit the home prior to making a decision. A relative confirmed that the staff from the home conducted an assessment in hospital prior to the individual moving to Woodland Grove. The pre-assessment included all aspects of daily living, a pen picture of the person’s life history, relatives, friendships and likes and dislikes. It also included how the person likes to spend their time. It was evident that the individual’s cultural and spiritual needs were discussed. From talking with some of the individuals living in the home it was evident they had been very active in choosing to live in Woodland Grove. One person said the staff are very helpful and I feel safe and I had visited a friend who lived here. Another person said that they had been welcomed into the home and liked living there and had settled in well to life at Woodland Grove. Contracts were in place detailing the services available, the room to be occupied and the fees. Individuals or their representative had signed these. Individuals are given a welcome pack on admission. This included the home’s statement of purpose, the complaints procedure, meal times and other important information including a copy of the home’s reports in respect of the Commission for Social Care Inspection now called the Care Quality Commission. This is commendable. There are presently 36 individuals living at Woodland Grove. The deputy manager was seen showing a number of people around the home during the visit. From talking with the support manager it was evident that the Trust was reviewing the vacancies so that these could be filled. However, it was evident from the discussions that many of the individuals pay a top up fee or privately fund their care to live at Woodland Grove. There was no formal guidance in place when an individual could no longer pay the fees however reassurances were given that it was the person’s home and external guidance would be sought from the local funding authority where individuals could no longer afford their care. A visiting professional stated in a survey that they were concerned when individual’s needs changed significantly and needed to move to nursing care that there was a lack of continuity for these individuals. Care plans were not amended to reflect the changes whilst they were waiting to move to nursing care. There was no evidence of this during the visit however the home should Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 11 be mindful and amend care documentation accordingly and ensure that the increased level of care is met. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Individuals can be confident that their health and personal care needs are being met. Good documentation is in place to guide staff. Good procedures and practices are in place to safeguard the individuals in respect of their medication. However, there are concerns that if a person was in pain and not prescribed medication they may have to wait until they can see a GP. EVIDENCE: An opportunity was taken to review four person’s care which enabled us to make a judgement on the quality of the care provision for the people living at Woodland Grove. There are presently 36 people residing at Woodland Grove. Each person had a folder containing a comprehensive assessment, care plan, medical notes and risk assessments. Care documentation indicated the support Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 13 the person required from the care staff and what the person was able to do for themselves. It was evident that individuals were encouraged to be as independent as possible. Each person had a risk assessment relating to nutrition, wound care management, mobility and manual handling to name a few. Where individuals had been identified as being at risk a clear plan of care was in place to minimise the risks. A concern was raised by one person about one individual wandering at night. It was evident that the staff were informed of the situation and monitoring closely with safeguards in place. However, this was not clearly documented in the form of a risk assessment. It was evident that the individuals concerned were being closely monitored and one person was soon to be moving from the home. However, this must be clearly documented in the interim ensuring that safeguards are in place for both persons. The care documentation was being reviewed although for one person this had not been reviewed in the last two months. Reassurances were given by the support manager and the deputy manager that quality audits are being completed on the care documentation and being addressed. In some cases staff were recording inappropriately for example one member of staff had written about social activities in the section about medical. The deputy manager said that all staff are completing further training in the care planning processes. A member of staff confirmed that they were planning to attend this training. No requirements were made during this visit as it was evident that the home was planning to address the shortfalls and were routinely completing audits in respect of the care planning processes. The health care needs of people who live in the home are met through the provision of community based health services such as chiropody, opticians and dentists all are available as required and on a regular basis. Each person is registered with a GP. Individuals confirmed that they had access to a GP and staff responded appropriately to concerns about health. Good records were maintained of appointments and any follow up treatment. Feedback from professionals was mixed. One GP said that the home worked closely with the surgery whilst another said that the home did not forward concerns promptly in respect of refused medication or general deterioration. This was echoed by a professional working for the Primary Care Trust. They said that staff did not always take on board the advice, do not complete charts consistently and do not report changes promptly. Care is very much dependent on who is working on that shift. This was echoed by some of the individuals living in the home with three individuals in completed surveys stating that if their key worker was on shift the care was better. One visiting professional Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 14 said that the home care varies depending on the dependence of the individual, where care needs increase care plans are not updated to reflect the level of care required and staff lack the training and leadership about how to deal with unwell patients or those requiring higher levels of care. At the time of the visit the deputy manager stated that all the individuals were well and mobile only requiring assistance with their personal care. Of the four person’s care seen it was evident that personal care needs of the individuals were being attended to and medical attention was sought appropriately. This was confirmed in conversations with three of the individuals who said they were happy with their care. District nurses visit individuals who require this service in respect of wound care management. Three staff were consulted in respect of wound care management and it was evident that there was good communication around this area. Presently there is only one person who has a pressure wound and this is being regularly reviewed by the district nurse. This person was admitted to the home with this wound. Staff appeared knowledgeable on the prevention and what to look out for and the importance of reporting. The home has a medication policy which guides them on the system in place. The home uses a monitored dosage system. It was recommended during the last visit that the home explore how individuals can be offered over the counter medication for example for mild pain relief etc. Whilst the home has a homely remedy policy there was no evidence that this had been explored. Staff stated that if an individual is not prescribed medication then this can not be given. None of the individuals spoken with raised this as a concern; good practice would be to seek advice from the GP on what homely remedies can be used for each individual. Staff said that if a person is in pain then they would have no hesitation in contacting the GP. However, this could take some time which could mean that a person could be left in pain until the GP responds. The home does not hold a stock of over the counter remedies which could mean that the individual will have to wait until the staff can access a chemist. It was noted that many of the individuals are prescribed medication for pain relief. All medicines seen were stored safely. A medicine fridge is available and a daily temperature recorded. These were in the appropriate range. Clear records were seen of medication entering the home, administration and disposal. Senior Carers have the responsibility for administering the medication where individuals are unable to self medicate. Where individuals self medicate a risk assessment was in place. Staff responsible for the administration of medication, have completed training as evidenced in conversations and the staff training record. Individuals confirmed in the completed surveys that they were treated with dignity and respect. Staff were observed knocking on doors and speaking to Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 15 individuals in a courteous manner. Individuals spoken with during this visit stated that the staff are responsive to their needs and indicated that they treated them well. The home operates a key worker system and it was evident from the surveys that they had built good relationships. One person said that they always liked it when their key worker was on duty as it was someone they could talk too. Another person said their key worker was accompanying them to a hospital appointment. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Individuals have meaningful activities offered to them on a regular basis. There is good consultation with individuals about what they want to do. Contact with the local community, relatives and friends are encouraged. Mealtimes are flexible with a nutritious and varied menu being offered. EVIDENCE: The home employs an activity co-ordinator 5 days per week. There was a schedule of planned activities throughout the week. Activities included arts and crafts, cooking, visiting entertainers, film and game afternoons, sing a long, reading and theme days. In addition to the activities organised by the activity co-ordinator visitors were welcomed to the home including a local school, a choir, the local museum and ministers from the local church. In addition to the group activities there was evidence that the activity coordinator spent time with individuals reading, chatting and nail care. From talking with individuals it was evident that the care staff were busy and had Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 17 little opportunity to spend quality time with individuals other than completing task orientated chores for example personal care. Staff said in the main it is the activity co-ordinator that spends time addressing the individual’s social needs. The home has an open visitor’s policy. A visitor’s book is maintained detailing the people who visit the home. Visitors confirmed that they could meet with their relatives in private or have access to the communal areas. A visiting relative said the staff are always welcoming and their relative appears happy and settled in the home. It is evident from talking with people who live in the home and from records that the home has built positive links with the local church and school. Children from the local school visit regularly and spend time with the people living in the home. The local church minister visits at regular intervals. The hair dresser visits on a weekly basis along with an aromatherapist. The home has a designated area specifically for the hair dresser. Monthly meetings are organised with the individuals living in the home seeking their views on menu planning, activities and day to day running of the home. A meeting had been prearranged for the day of the visit and it was evident that attendance was good with approximately twenty people attending. From completed surveys it was evident that the individuals living in the home have benefited from the improvements in how meals are served. It was noted that individuals were not happy about this aspect of their care during the last visit. A member of staff is employed to assist with this area ensuring that meal times are stress free and relaxed. No concerns were raised in conversations with individuals or through the surveys received prior to the visit. Individuals have available to them a nutritional and healthy diet. Individuals have a choice of main meal with alternatives in the form of snacks. The chef seeks the views of the individuals and caters for likes and dislikes. Three of the individuals are vegetarian and options are available for them. Care records included nutritional assessments and risk assessments where relevant. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Individuals are supported to express their views about the service being provided and the running of the home. Concerns were being addressed by the staff in the home. Individuals can be confident in the home’s procedures in relation to safeguarding. EVIDENCE: The home’s complaint procedure is clearly displayed in the foyer of the home and is included in the statement of purpose. Individuals are given copies as part of the welcome pack. Individuals in completed surveys said they were aware of how to complain. One individual said that the deputy manager has been proactive in resolving concerns. Individuals views are consulted through regular house meetings and it was evident that where issues have been raised these are addressed. An example of this was that the people living in the home were not happy with the new crockery saying they were too heavy. The deputy manager was working closing with the catering manager to address the issue with individuals being consulted on their replacement. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 19 The home maintains a complaint record. There have been 13 complaints since the last visit. Most of these have been addressed. Some of these concerns were forwarded to Anchor Trust from Bath and North East Somerset Council and related to fees and care. Anchor has investigated these and kept the Care Quality Commission and Bath and North East Somerset Council informed throughout. Part of this action has meant that there have been some changes in the management and administration of the home. A short embargo was put on the home as an interim measure by BANES, this has now been lifted with people now being placed. Staff have attended training in Safeguarding and those spoken to were aware of the procedures to follow and what constituted abuse. Safeguarding polices were seen during the previous visit and were not reviewed on this occasion. Individual’s belongings could be better protected. There was no evidence of an inventory of belongings on their admission to the home. One person has recently lost a ring whilst there is no foul play suspected better protection of people’s belongings should be in place. A relative stated the staff have been vigil in looking for the ring and she was impressed in the communication between the management and staff during this time. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Woodland Grove provides a safe and comfortable place for individuals to live that is meeting their needs. EVIDENCE: Woodland Grove is a large impressive building set in private grounds in keeping with the local neighbourhood. Woodland Grove is a converted Victorian building spread over three floors. The bedrooms are called flats. These are set out like a small bed sit with a kitchenette and ensuite bathroom. On the top floor there are four self contained flats with a small lounge/kitchen area, a separate bedroom and Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 21 bathroom. All bedrooms are lockable and offer individuals their own private space. The Annual quality Assurance has identified that where rooms become vacant these are going to be refurbished with new carpets and decoration being undertaken. In addition the lounge and the dining room curtains are being replaced. The home was maintained to high standard and was clear and free from odour. The home employs domestic staff to assist with the day to day cleaning of the home. All completed surveys except one said the home was always clean, with one identifying the communal bathrooms as being an area of concern. Although on the day of the visit these were clean and free from odour. A domestic staff said that communal areas and bathrooms are cleaned daily, with bedrooms cleaned on a weekly basis unless it has been identified for more frequent cleaning. The home has recently had a complete kitchen refurbishment. There have been some minor issues which are being addressed by Anchor Trust. This has included a new gas pipe having to be installed outstanding works are replacement of the industrial fryer and for new extractors being installed. The chef stated that both of these are being completed. The kitchen has recently been inspected by Environmental Health and one of their recommendations was the kitchen should have a larger extractor fan. The home employs a maintenance person to complete day to day repairs and decoration of the home. This person is responsible for completing health and safety checks in respect of the general up keep of the building, water temperatures and fire. This person said that they had completed training in this area including risk assessments. Records were maintained of the repairs and it was evident that these were addressed promptly. The home has specialist equipment including a lift, hoists, bathing and manual handling aids and hand rails strategically placed throughout the home. Evidence was provided that these were routinely maintained by external contractors. The home has a Loop system in the dinging area. All areas of the home are heated and bedroom radiators are fitted with thermostatic controls. Water is regulated to ensure a safe an even temperature. Records of these were maintained. The home has a separate laundry facility with a member of staff having responsibility for this area. It was well organised with appropriate industrial washing machines and dryers in situ. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 22 Hand washing facilities were available throughout the home. Staff have available gloves and aprons to prevent cross infection. The annual quality assurance assessment provided evidence that all staff have attended training in good infection control including hand washing training. Polices and procedures were in place for prevention of cross infection as seen at the last visit. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Sufficient staff support the individuals living at Woodland Grove. There is a good basic rolling programme of training which would be enhanced if areas covered included specific care issues relating to the people they support. Individuals are protected by a thorough recruitment process being undertaken. The home has been through an unsettling time due to the management changes and a high turnover of staff, however it would appear that this is changing with a more cohesive and supportive team being developed. EVIDENCE: The home is staffed with a minimum of three care staff and one team leader during the day and then two care staff and one team leader in the evenings. The home is staffed at night with two waking carers and one sleep in member of staff. The home was in the process of reviewing the staffing as the home presently has 36 people living there. When the home is fully occupied the deputy manager stated that there will be a minimum of five care staff and one team leader working in the home during the day. Some shifts are now covered by four or five care staff. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 24 In addition to the care staff, housekeeping staff are employed to complete the catering and household chores. An activity co-ordinator is employed Monday to Friday. There is also an administrator post being advertised. Staff spoken with during this visit said that the staffing has recently improved with more permanent staff being taken on. However, comments from individual surveys stated that when their key worker is on duty they get a better service. It would be recommended that this is explored to see why individuals feel this way. The Annual Quality Assurance Assessment indicated that ten staff have left in the last twelve months. Staff stated that during this time staff working in the home have covered these hours ensuring continuity for the people living in the home and it is rare that agency staff are employed. The deputy manager stated there has been a recruitment initiative and the home is nearly fully staffed and the plan is to recruit a number of relief staff to cover holidays and absences. Recruitment and selection records showed that the necessary checks had been completed. This included a criminal record bureau check, two references and application forms which provided a full and detailed information about employment history. Health questionnaires are also completed. Policies and procedures were in place relating to employment and equal opportunities. The home keeps records of interviews this is good practice and further demonstrated a thorough recruitment process had been undertaken. Newly appointed staff attend induction training and are shadowed by more experienced staff. Records were maintained of the induction and the areas covered. Once staff complete their induction they then proceed to complete a National Vocational Award. According to the Annual Quality Assurance seventeen staff out of twenty six have a National Vocational Award at level 2 or 3 depending on role within the home. Senior Carers are presently completing an NVQ at level 3. Training records indicated that there was a good rolling programme of health and safety training. This included first aid, back care (manual handling), fire and safeguarding training. Where there were gaps the deputy manager could demonstrate that training was planned. Other training included dementia care, nutrition and care planning training again this was limited as noted at the last visit. The deputy manager said that further training is being offered to staff on dementia in April 2009. Three of the staff have been awarded a “Dignity Champions” award. It was noted that some staff had attended training in equal opportunities and dignity in eating. Some of the senior carers were planning to attend training relating Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 25 to the Deprivation of Liberties Act and the Mental Capacity Act. Information was available in the foyer of the home to staff and the people who use the service on this new legislation. It is evident from reading the Annual Quality Assurance Assessment that further plans for improvement have been identified in relation to staffing including the employment of a Housekeeper to supervise and monitor the domestic staff, decreasing staff turnover with incentives and an Employee of the month scheme and increasing staff supervision to monthly and developing a training plan for team leaders. This will be followed up at the next visit to the home. There were mixed views on the staff training, one person highlighted that they wanted to attend a course with the local Hospice Care but was denied it. This was discussed with the deputy manager who said that there were limited places and they do not offer it at regular intervals. The deputy manager said that the team leaders went on this training but she would explore how this could be cascaded to other team members. One member of staff said that Anchor offer a good training package. From talking with the staff and from completed surveys it is evident that the home has gone through a period of change which has affected the morale of the staff team. Staff spoken with and one survey indicated that this is changing and a more cohesive team are being developed although they are aware that there are more changes ahead with the recruitment of a new manager. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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 home is going through a period of management change. However it was clear that interim measures have ensured that this has meant little disruption to the people living in the home. Individuals living in the home are actively involved. The safety of the individuals is paramount with good systems in place. EVIDENCE: The home has been through a period of change in management. The manager has recently left the employment of Anchor Trust and the deputy manager has been acting in this role since February 2009. Managers from two other homes Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 27 are visiting the home on a regular basis along with the area manager. Recruitment interviews are taken place over the next month for a new manager and an administrator for the home. In talking with staff and the people who use the service positive comments were made about how the deputy manager has continued to manage the home. Individuals said that the deputy manager was approachable. Quality Assurance was not discussed as a topic, but it was evident that regular audits were taken place including health and safety, environmental, care planning and medication audits to name a few. The deputy manager stated that annual quality assurance questionnaires are sent to relatives and people who use the service. It was noted there were some improvements to be made in the area of catering and meal times during the last visit to the home. It was evident from talking with individuals and from the completed surveys received prior to this visit that this has now improved. The home has employed a new cook since the last visit. Individuals can use a comment book which is situated in the dining room. It was evident from talking with the cook that the comments recorded would be acted upon. The Annual Quality Assurance Assessment stated that meal times are more flexible. The home has reviewed how it delivers food to individuals who choose to stay in their bedrooms ensuring it is hot. Individuals living in the home are involved in discussions about the running of the care home including meals, activities, staffing and décor. It is evident that their views are acted upon. There was a meeting on the day of the visit and it was noted that there was a good attendance. Individuals said that the meetings are monthly and it is a good way to keep up to date about changes. In addition the home writes a monthly newsletter which is circulated around the home and to relatives. Staff meetings are happening regularly and it is evident that staff can voice their concerns and openly discuss issues relating to the running of the home. In addition staff receive six weekly supervisions and annual appraisals. The maintenance person had responsibility for the health and safety of the home. Good records were seen relating to Safety data information (as part of COSSH), routine maintenance of equipment including fire. Fire records were well maintained including training. Less apparent was night staff taking part in a six monthly fire drill. The deputy manager said that she was unaware and would rectify this over the next three weeks as some staff were on annual leave. Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 28 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 2 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 29 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 OP1 Regulation 5 Requirement For the home to ensure that the statement of purpose is kept under review. This must include the number of people that the home support and the changes in management. To risk assess individuals that may wander at night and ensure safeguards are in place. To review the homely remedies policy to ensure that individuals and their GP are consulted about over the counter medication. This will ensure that individuals remain pain free. Ensure that all staff including those that work at night attend a fire drill once in a six month period. To maintain an inventory of service user’s belongings, which is completed on admission and periodically updated. Timescale for action 07/05/09 2. 3. OP7 13 (4) 12 13 (2) 12 (1) 09/04/09 07/05/09 OP9 4. OP38 23(4) (e) 21/04/09 5. OP18 17 (1) Schedule 4 (10) 07/05/09 Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodland Grove DS0000008163.V374755.R01.S.doc Version 5.2 Page 31 Care Quality Commission South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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