Care Home: Woodland Manor

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What the care home does well During our visit we spoke with seven people who shared their experiences of what it is like for them, living in the home. They told us, they are able to spend their time as they wish and that they receiving a good service. People told us, ‘I have been here about nine months and found it very difficult to settle, having moved from my own home, however the staff and my relatives have helped support me to make this change in my life” and “I could not have picked a better home, I am able to go out for walks when I choose and I brought my bird table with me, so I can watch the birds from the window, I am quite content here” and “I have a lovely room, I was able to bring my own furniture and have been able to create a small potted garden on my balcony. The staff are superb, really lovely, both the young and the older staff are very dedicated, I have no complaints”. A relative told us, “I can not fault the home, my relative is really well looked after, the staff are very kind, not only to my relative but as a regular visitor to the home, I notice what they do for the other residents”. They also told us, “my relative can be difficult at times, there health is deteriorating and they are finding it increasingly difficult to attend to their own personal care needs, however the care and support from staff is really good”. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 What has improved since the last inspection? Improvements have been made to ensure people receive a varied, wholesome and nutritious diet. Additionally, flexible dining has been introduced, residents are no longer required to pre order off the menu. People described the food as ‘lovely’ and told us, that they always get good food with plenty of choice. They also commented, “we get beautifully waited on and well looked after here, we can eat in our rooms, if we choose, we do not have to eat in the dining room, we could not be better looked after”. To ensure there is an effective audit trail of medication, information provided in the AQAA and verified at the inspection, identified that a National Contractor has been introduced to monitor and deliver training on medication for all Anchor Homes. They have also implemented a new audit programme for all aspects of medication storage and administration and are in the process of developing a system to collate medication errors, across all Anchor Homes services and respond to themes in practice. Anchors Homes are in the process of reviewing the adult protection processes in line with new vetting and barring procedures and the Independent Safegurading Authority (ISA), to further safeguard people using their services. A redecorating programme, is currently underway, to ensure people living in the home live in pleasant and comfortable surroundings. Contractors were seen on the premises, during the day of the inspection, redecorating all communal areas. What the care home could do better: The flooring in the laundry were the washers and dryers are located has previously been re-surfaced and sealed with floor paint, however this was now pealing, therefore the floor is not adequately sealed, to prevent any potential infections being spread. The location of the laundry and the décor has previously been raised with the registered manager, who informed us consideration being given by Anchor Homes to relocate the laundry, but as this was not looking to be imminent and the refurbishment of the laundry is now overdue. Key inspection report CARE HOMES FOR OLDER PEOPLE Woodland Manor Whitton Park Thurleston Lane Ipswich Suffolk IP1 6TJ Lead Inspector Deborah Kerr Key Unannounced Inspection 9th July 2009 09:00 DS0000060707.V377170.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 Manor DS0000060707.V377170.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 Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland Manor Address Whitton Park Thurleston Lane Ipswich Suffolk IP1 6TJ 01473 461622 01473 462298 lesley.tournay-godfrey@anchor.org.uk www.anchor.org.uk Anchor Trust 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) Miss Lesley Tournay-Godfrey Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 One named individual to be accommodated with learning disability (LD) 6th August 2008 Date of last inspection Brief Description of the Service: Woodland Manor is situated within Whitton Park and is set in extensive grounds. There is adequate parking to the front and the nearest public bus stop is a short walk from the home. The building is a large Victorian House, which has been extended to incorporate a three-storey block comprising two floors of care home accommodation. The ground floor of this block comprised a mixture of care home bedrooms and a privately occupied flat that was not part of the registered premises. The home has four floors and accommodation comprises of twenty seven single and two double en–suite rooms, and four single rooms, with hand wash basins installed. Four rooms have bath and shower facilities and two have en-suite bathroom and kitchen facilities. There is also a large lounge with an adjoining dining room. There is a further lounge/dining area near to the kitchen and two smaller quiet lounges in the extension. Anchor Trust has produced a colour brochure and compact disc providing detailed information about the home and the range of services and facilities. It also contains a copy of the home’s terms and conditions of residence and a copy of the complaints procedure. These are available on request and can be provided in large print and other languages. The home offers accommodation in the category of elderly people who require personal care. Each person is issued with a contract, which specifies their agreed fees and how much they are expected to pay on a weekly basis. Fees are calculated depending on the needs of the individual and range from £362 to £694.00 per week. This was the information provided at the time of the inspection; people considering moving to this home may wish to obtain more up to date information from the care home. Hairdressing, chiropody, toiletries and newspapers not covered in the fees and are charged at additional cost. Woodland Manor DS0000060707.V377170.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 a key inspection, which focused on the core standards relating to older people. The inspection was unannounced on a weekday, which lasted nine hours. This report has been written using accumulated evidence gathered prior to and during the inspection, including information obtained in the Annual Quality Assurance Assessment (AQAA) issued by the Care Quality Commission (CQC). This document gives the provider the opportunity to inform CQC about their service and how well they are performing. We also assessed the outcomes for the people living in the home against the Key Lines Of Regulatory Assessment (KLORA). A tour of the premises was made and a number of records were inspected, relating to people using the service, staff, training, the duty roster, medication and health and safety. Time was spent talking with the deputy manager, the administrator, seven people living in the home, a relative and two staff. The manager was on annual leave, but came in to be present during the inspection and fully contributed to the inspection process. What the service does well: During our visit we spoke with seven people who shared their experiences of what it is like for them, living in the home. They told us, they are able to spend their time as they wish and that they receiving a good service. People told us, ‘I have been here about nine months and found it very difficult to settle, having moved from my own home, however the staff and my relatives have helped support me to make this change in my life” and “I could not have picked a better home, I am able to go out for walks when I choose and I brought my bird table with me, so I can watch the birds from the window, I am quite content here” and “I have a lovely room, I was able to bring my own furniture and have been able to create a small potted garden on my balcony. The staff are superb, really lovely, both the young and the older staff are very dedicated, I have no complaints”. A relative told us, “I can not fault the home, my relative is really well looked after, the staff are very kind, not only to my relative but as a regular visitor to the home, I notice what they do for the other residents”. They also told us, “my relative can be difficult at times, there health is deteriorating and they are finding it increasingly difficult to attend to their own personal care needs, however the care and support from staff is really good”. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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 Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6, 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. People who may use this service are provided with information they need to help them choose if this service will meet their needs. EVIDENCE: Copies of the statement of purpose and service users guide were provided at the inspection. A corporate, Anchor Homes Statement of Purpose was introduced in 2006, which contains an insert providing information specifically about Woodland Manor. Both documents contain detailed information about the services provided, the facilities and also includes the complaints procedure. The Service User Guide is being translated into a selection of other languages. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 9 Information provided in the AQAA and verified at the inspection confirmed Woodland Manor has a comprehensive admissions policy and procedure to ensure that prospective users of the service are made aware of what the home has to offer. The records and care pathways of three people living in the home were tracked, to ascertain how well the home is meeting their individual needs. All three people tracked had a detailed pre admission assessment completed, which covered all areas of their health, personal and social care needs. Additionally, a baseline assessment had been completed within twenty four hours, to assess the individual’s mobility, lifestyle choices, emotional and physical wellbeing at the time of moving into the home. The manager and senior staff have recognised qualifications to enable them to undertake the pre admission assessments. Individuals are encouraged to be involved with the assessment process and information is gathered from a range of sources with the individual’s agreement. People thinking of using the service are encouraged to visit the home and spend time getting to know staff and other people living there. People spoken with confirmed they or their relative had had been provided with information and the opportunity to visit the home, before deciding if was the right place for them. Where people had been referred through social services a copy of the social workers assessment had been obtained and held on their file. These and information obtained in the pre admission assessment are used to produce an holistic care plan, which takes into consideration the individual’s life history and current needs and choices. To ensure the home are able to meet peoples’ specific needs, where identified, people using the service are referred to specialist services. Care plans reflected there has been input from health care professionals, such as the Mental Health Intermediate Care for Older People (MHICOP) team, community physiotherapist, occupational therapist and the district nurses. Additionally, staff are provided with training to ensure they have the knowledge and skills to provide care and support appropriate to the needs of the individual(s). Each of the files seen contained a copy of the individual’s terms and conditions of residence at Woodland Manor setting out their fees, the roles and responsibilities of the provider and their rights and obligations whilst living in the home. The home does not provide intermediate care. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11, 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. People who use this service receive health and personal care, based on their individual needs. EVIDENCE: Information provided in the AQAA and verified at the inspection confirmed people’s needs are clearly outlined in their Service User Plan. Three peoples care pathways and service users plans were tracked as part of the inspection. These had photographs in place of individual residents to identify and personalise the care plan document. The plans are divided in to eight sections, which include personal life and medical history, care plans, assessments, medical / professional interventions, reviews, support plans and risk assessment and historic information. These collectively set out the actions required by care staff to ensure that peoples’ health, personal and social care needs are met and describe the expected outcomes for the individual. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 11 Peoples changing needs are documented through a daily recording system, review and evaluation processes. The daily records are well written and provide a good overview of how each individual has spent their day, they also document the care provided and give an indication of the individual’s health and well being. ‘Alert sheets’ are used as a communication tool to ensure vital information about residents is transferred between the care teams. Staff spoken with were able to give a verbal account of the needs and preferences of individual residents. Conversation with people living in the home confirmed that staff treat them with dignity and respect. The interactions between residents and staff were observed to be friendly and appropriate. A referral system is in place to ensure people in the home are able to access health care services and social care professionals. Peoples nutritional needs are closely monitored with regular weight checks being undertaken. The home has a positive relationship with the local General Practitioners (GP) and district nurses, who make regular visits to the home. Dates and details and outcomes of appointments had been clearly recorded, in peoples care plans. Additionally, the AQAA reflects staff in the home have improved their knowledge of local health and social care resources to meet people’s needs, examples provided are loan of specialist equipment and specific services like memory clinics. Supporting risk assessments are in place, identifying the risks for activities of daily living, such as mobility and personal hygiene and the action required by staff to minimise these, whilst enabling the individual to retain some independence and choice. For example, moving and handling assessments, clearly reflect the aids and equipment needed, including where required , the type of hoist, size of the sling assessed to meet that individuals needs and number of staff required to complete task. Additionally, care plans contain individual Personal Emergency Evacuation Plans (PEEP) providing good information to staff of the best and safest way to support the individual in an emergency situation. Information provided in the AQAA and verified at the inspection confirmed the home has robust medication polices and procedures in place. Time was spent with the senior observing them administer the lunch time medication. The home uses the Monitored Dosage System (MDS). Photographs of residents had been attached to the Medication Administration Records (MAR) charts folder to avoid mistakes with the persons identity. The practice of administering medication is being generally well managed. The MAR charts inspected were found to be completed correctly, staff had made good use of the codes to reflect if medication had not been administered and the reason why. The home has a small medication fridge, which is kept locked and was found to be operating at the correct temperature. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 12 A check of the medication cupboard reflects the cabinet meets with the required specifications, for storing controlled drugs. There are currently three people prescribed the controlled drug, Temazepam, living in the home. A check of the blister packs for each individual’s Temazepam was checked against the controlled drugs register and found to be accurate. The AQAA told us that a National Contractor has been introduced to monitor and deliver training on medication for all Anchor Homes. They have implemented a new audit programme for all aspects of medication storage and administration and produced information and guidance for the people assessed as competent to self-medicate. Additionally, they are in the process of developing a system to collate medication errors across all Anchor Homes services and respond to themes in practice. Peoples care plans contained information about their wishes at the time of, illness, death and dying. The manager confirmed they are in the process of improving these to include end of life care, (as per the Liverpool Care Pathway) to ensure fulfilment of individual wishes. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are provided with activities that meet their expectations and which meets their social and recreational interests. EVIDENCE: Care plans viewed contained individual’s life histories, providing a good profile of the person. These provided information of the individual’s past, focusing on significant and important events in their life, what matters to them and why. This information provides vital links to the persons past, which has formed their identity, and forms the basis of communication and provides staff with an understanding of the individual. The AQAA states the service has implemented person centered planning and are working towards changing the culture of the traditional work force, through an ongoing training programme to break away from the focus of group activity, to more individual focused activity. This was verified at the inspection, there are no set routines and that the day is set by the care planning process and individual needs on a daily basis. Activities are provided in a sensitive way Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 14 according to peoples needs and as outlined in their care plans, which reflect their individual interests and the activities they have taken part in. These included, quizzes, musical entertainment brought into the service, a pantomime, fish and chip supper, exercise sessions, manicures, a strawberry tea, a memorial garden lunch and shopping excursions. During our visit we spoke with seven people who shared their experiences of what it is like for them, living in the home. They told us, they are able to spend their time as they wish and do take part in some of the activities or choose to spend time in their room or communal lounge. Comments included, ‘I have been here about nine months and found it very difficult to settle, having moved from my own home. The staff and my relatives have helped support me to make this change in my life, I lost weight initially, but I am eating better now and have re gained some weight” and “I spend my time in my room mostly out of choice, reading the paper and doing the crossword and watching sport on the television”. Other comments included, “I could not have picked a better home, I am able to go out for walks when I choose and I brought my bird table with me so I can watch the birds from the window, I am quite content here” and “I have a lovely room, I was able to bring my own furniture and have been able to create a small potted garden on my balcony. The staff are superb, really lovely, both the young and the older staff are very dedicated, I have no complaints”. A relative told us, Woodland Manor is lovely, it is in a lovely setting, and the food is really nice, I am going to put my name down to move here” and “I can not fault the home, my relative is really well looked after, the staff are very kind, not only to my relative but as a regular visitor to the home, I notice what they do for the other residents”. They also told us, “my relative can be difficult at times, their health is deteriorating and they are finding it increasingly difficult to attend to their own personal care needs, however the care and support from staff is really good”. People told us, they can come and go from the service as they please and are supported to maintain contact with relatives and friends. One person said they continue to attend their local church, women’s meetings where they meet up with old friends. Another person told us, they go out using a taxi service to meet friends for coffee. The visitor’s book reflects there are regular visitors to the home. The inspector joined a group of residents whilst they were having their lunch. The menu consisted of steak and onion pie or vegetable risotto, with dauphinois potatoes and a selection of seasonable fresh vegetables, followed by stewed apple and custard. The food smelt nice and looked appetising People described the food as ‘lovely’ and told us, that they always get good food with plenty of choice and there is always a vegetarian option. They also Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 15 commented, “we get beautifully waited on and well looked after here, we can eat in our rooms, if we choose, we do not have to eat in the dining room, we could not be better looked after”. Time was spent talking with the chef manager. They told us that they have many years of experience working at the home. They confirmed they have seen a lot of improvement in the service, people are provided with a lot more choice, they get anything they ask for and we do not always stick to the menu. We often have three of four choices. We try to cater for all people’s tastes and preferences. There is no one currently living in the home that requires a special diet. The food is all fresh produce, which is home cooked. Other people told us, “the food is very good, we are provided with menus, if we do not want what is on the menu, the cooks are very kind, there is nothing that they will not do for you” and “we have three great chefs, the food is great”. All three catering staff have completed a National Vocational Qualification, in catering at diploma level, called Catercraft. Additionally, the chef manager has completed an intermediate certificate in food hygiene. Having completed the course they are now a verified assessor and able to assess other Anchor staff. They told us, the training has provided them with a lot of new ideas, which has improved the menus. As part of the training they had to complete 144 recipes, all in different categories. They took samples around to residents in little dishes to encourage them to try different foods and have introduced more fish dishes as a result. The AQAA reflects, improvements have been made to incorporate flexible dining, residents are no longer required to pre order off the menu, additionally the dining area has been redesigned, so that people have a choice of where to eat their meals. Additionally, plans are in progress to develop picture boards for menu choices, where communication is a barrier. Woodland Manor DS0000060707.V377170.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, 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. People who use this service have access to a robust and effective complaints procedure and are protected from abuse. EVIDENCE: The policies and procedures for dealing with complaints, whistle blowing and safeguarding the people living in the home were examined. People using the service and staff confirmed they were aware of the complaints procedures and were clear they would talk to the manager if they had any concerns and were confident that there concerns would be dealt with. Residents and staff told us the manager, is very approachable and I feel able to discuss any concerns openly with them. Information porvided in the AQAA and verified at the inspection confirmed the manager welcomes complaints as a mechanism to improve service. Complaints, concerns and compliments surveys are aslo used as part of the quality assurance monitoring of the service. Questionaires were seen asking people for their feedback, on how well the service are doing, if they wished to make a compliment or raise any concerns. This information is sent to Anchor Homes head office, business services team, where they are logged on data base and monitored. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 17 The organisation has a robust complaints policies and procedures in place. The procudere is made available to people using the service and their relativies in the statement of purpose, notice boards, leaflets and in the service users guide. The procedures provide clear guidelines of responsibility and what to do if more serious concerns are rasied and includes the expected response times for dealing with complaints. The complaints log was seen, which reflected three compaints have been made about this service, in the last twelve months. Information in the log book confirmed all three complaints had been investigated and feedback to the complainant, who were satisfied with the outcome. Policies and procedures are in place to protect the the people using the service from neglect and absue, which identifies the actions staff should take if an incident of abuse is discovered or reported to them.The AQAA reflects improvements have been made to the service by introducing an Anchor Care Governance Committee, led by Anchor’s Head of Care and Clinical Governance. They have appointed a Care Specialist to support a consistent approach to adult protection, and ensure processes are in place to monitor and feedback themes and lessons learnt. An ‘Alert Line’ especially for staff has been implemented and information leaflets are available throughout staffing areas, which staff are being encouraged to use. There are further plans to review Anchors, adult protection processes in line with the new vetting and barring procedures and the Independent Safegurading Authority (ISA), to further safeguard people using their services. The home continues to let us know about things that have happened in the home and they have shown that they have managed issues well. The manager raised a safeguarding referral following allegations made by an individual living in the home, about a member of staff. The adult safeguarding team agreed for the home’s manager to investigate the allegations. A disciplinary investigation was completed in line with the homes policies and procedures and the outcome feedback to us and the safeguarding team. Time was spent talking to the individual who made the allegations and they confirmed they were satisfied with the outcome. Staff files seen confirmed all staff are subject to Criminal Records Bureau (CRB) checks prior to commencing employment. Staff spoken with were clear about their role and their duty of care to raise any concerns they may have about other members of staff conduct and in reporting of incidents of poor practice and suspected situations of abuse, including reporting to incident to the local authority safeguarding team via Social Services, Customer First service. Woodland Manor DS0000060707.V377170.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26, 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 Manor provides people who live there with a safe, well maintained and homely environment. EVIDENCE: Woodland Manor is a large Victorian House, which has been extended to incorporate a three storey block. The home has four floors, with twenty seven single and two double en–suite rooms, and four single rooms, with hand wash basins installed. Four rooms have bath and shower facilities and two have ensuite bathroom and kitchen facilities. There are three toilets, one with disabled access on the ground floor, an assisted bath on the ground floor, assisted shower and bath on the third floor and two assisted baths on the second and fourth floor. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 19 Information provided in the AQAA and verified at the inspection confirmed the home is welcoming and provides a homely environment, with good quality facilities, domestic style furniture, lighting, carpets and curtains. There are a range of communal areas, which include a large lounge with an adjoining dining room. There is a further lounge/dining area near to the kitchen and two smaller quiet lounges in the extension and a hairdressing salon The home remains clean and odour free. People living in the home are encouraged to personalise their rooms, and to add finishing touches of their own to make their living space more homely. These were nicely decorated with people’s personal effects to reflect their individual personalities, hobbies and interests. The home is undergoing a redecorating programme. Contractors were seen on the premises, during the day of the inspection, redecorating all communal areas. The AQAA states further improvements are to be made including, purchasing new carpets for to corridors, re decoration of bedrooms, purchase new armchairs and for the home to be thermally insulated. The home is generally equipped with aids and equipment to promote mobility and maximise peoples independence, there are a range of hoists, grab rails and other aids, which are available in corridors, bathrooms, and toilets, and where required, and in residents own rooms. Record kept in the home confirmed all equipment is being regularly serviced as per the manufacturer’s recommendations. A call system is provided throughout the home, including individual’s rooms and all communal areas, so that residents’ have access to staff when they need them. The laundry facilities contain the appropriate equipment to launder soiled linen, clothing and bedding. Red dissolvable bags are provided for dealing with soiled linen, soiled garments and bedding are placed directly into the bag and into the washing machine on a sluice cycle minimising staff contact and the risk of spreading infection. Appropriate protective equipment, such as aprons and gloves and hand washing facilities of liquid soap and paper towels are provided in the laundry, all en suite and toilet facilities, where staff may be required to provide assistance with personal care. Concerns have previously been raised about the laundry, which is located in the cellar, accessible by lift. The flooring in the main areas of the laundry where the washers and dryers are located have been re-surfaced and sealed with floor paint, however this was now pealing, therefore the floor is not adequately sealed, to prevent any potential infections being spread. Other rooms in this cellar, which house linen and ironing facilities are still carpeted, as are the corridors in this area. These carpets were worn, solid and generally in poor condition. This has previously been raised with the registered manager, who has acknowledged this and has informed us consideration is to be given Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 20 by Anchor Homes to relocate the laundry, but as this was not looking to be imminent and the refurbishment of the laundry is now overdue. The door to the laundry was wedged open with a large container of cleaning fluid, the laundry staff confirmed this was only whilst they were working in the laundry, all other times the door is closed. Windows on the landing on the second floor and bathrooms did not have window restrictors fitted, to safeguard people from the dangers of falling through windows, however the manager provided evidence to show that these were to be fitted on the 16/07/2009. Additionally, it was noted that the arm on the stair lift at the top of the main stairs, was broken, the arm would not stow in the upright position, and was blocking access across the landing. The manager confirmed the spring has broken and that a replacement has been ordered. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29, 30, 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. People using this service are supported by a staff team that are available in sufficient numbers and who are trained, skilled and competent to do their jobs. EVIDENCE: Information provided in the AQAA and verified at the inspection confirmed improvements have been made to reduce the use of agency staff providing greater continuity of staffing to people living in the home. The duty roster reflects the home is staffed twenty fours a day, seven days a week. The normal staffing ratio is a team leader plus four care staff, between 7.30am and 2.30pm. The afternoon shift is staffed by a team leader and three staff, (four, if possible), between 2.30pm to 9.30pm, Nights are covered by a team leader and two waking staff. There was evidence from the staff rota, discussion with residents and staff that staffing levels are well maintained, The AQAA reflects the home has a robust recruitment processes in place, to select the right candidate and to protect the people living in the home. Examination of three staff files confirmed all relevant documents and recruitment checks, required by regulations, to determine the fitness of the worker had been obtained prior to them commencing employment. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 22 Records and discussions with staff confirmed they had been recruited fairly and that they received good training and support to ensure they have the skills and knowledge to do their jobs and to meet the different needs of the people living in the home. Most recent training has included first aid, back care/manual handling, care of medicines, Safeguarding Vulnerable Adults, (SOVA), health and safety, food hygiene and fire safety. More specific training to meet the needs of the people using the service has included dementia awareness, service user plan training and dining with dignity. Additionally, Anchor Homes have introduced e learning (computer based training) offering staff more flexibility in the way on which they learn. The AQAA states the service has a comprehensive National Vocational Qualification (NVQ) training programme. The manager and a senior member of staff are trained NVQ assessors, with a further two senior staff working towards completion of the assessor’s award. The home has twenty five permanent and bank care assistants, who work full and part time hours. Fourteen staff have completed an NVQ 2 or above. These figures reflect the home has 50 of staff who hold a recognised qualification, which meets the National Minimum Standard (NMS). The AQAA tells us, the service intends to achieve 80 of staff will have an NVQ qualification, by March 2010. Anchor Homes have produced their own induction booklets for care staff, which meet the Skills for Care, Common Induction Standards (CIS). Records seen and staff spoken with confirmed they had received a very good induction, which included an orientation tour of the home, introduction to Anchor Homes care home procedures, health and safety issues, personal care, and moving and handling. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 23 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): 31, 33, 36, 38, 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 management and administration of the home is based on openness and respect and is run in the best interests of the people living there by a competent and qualified manager. EVIDENCE: Lesley Tourney Godfrey is the registered manager for this service. They have sixteen years experience of working in care and has been the manager of Woodland Manor for approxiamatley five years. They have a range of qualifications to support their position as manager, which include a Diploma in the Management of Care Services, Level 4 and currently working towards Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 24 completion of the Registered Managers Award (RMA). They are an NVQ assessor and verifier and has completed foundation training in the care of medicines. To ensure the home is run in peoples’ best interests, an annual quality monitoring system is in place, which seeks the views of residents, relatives and staff. People using the service are provided with opportunity at regular residents meetings to have their say about how the service is being run and managed. Additionally, the heads of departments and staff meetings are held on a regular basis, which are used to consult with staff and provide information to further develop the service. The AQAA reflects the service has a home’s business plan, which outlines the development of the service and the plans for the future.This was seen displayed on the notice board in the entrance hall for residenst and vistors to see. Monthly quality indicator reports, seen at the inspection, form part of the monitoring process. These reflect what has occurred in the home during that quarter and how things have been managed. The most recent quality monitoring survey completed was completed in June, this year to obtain feedback from people using the service on the quality of catering and mealtimes. Feedback on the whole was mostly positive, comments included, “I like the meals here a lot, meal times are catered for very well, compliments to the cooks” and “I am very happy with all my meals” and “I am very happy with all my meals, I do not have a bad word to say”. Other people, commented, “the tea time times are a bit rushed” and “sometimes have wait a long time between courses” and “certain people could use more help at meal times”. Staff files confirmed that regular supervision takes place. The documentation reflects that these sessions include discussion about achievements since last the last meeting, any problems, strengths and weaknesses are discussed, the individuals approach to job and areas of development and training needs. Handling of people’s finances were not inspected on this occasion, these have been fully explored at the two previous inspections. Anchor Homes have developed systems to encourage the people living in the home to manage their own financial affairs. However, where they are unable to do this the administrator helps support individuals to manage their personal finances. A database provides an audit trail of expenditure. Each person has their own account, which we were told was managed by the administrator. A database provides an audit trail of expenditure where money is withdrawn and a record of their personal allowance is paid in. To ensure the safety of people living in the home, all radiators are guarded with purpose built radiator covers, which minimises the risk of people falling against them and sustaining burns. All hot water outlets to baths, hand wash basin and showers have been fitted with thermostatic valves, which regulate Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 25 the temperature of the water, to ensure these do not exceed the safe recommended temperatures. The premises complies with the fire service requirements, however as already mentioned, windows on the landing on the second floor and bathrooms did not have window restrictors fitted, to safeguard people from the dangers of falling through windows, evidence was provided to show that these were to be fitted on the 16/07/2009. The home takes steps to safeguard the health, safety and welfare of people living and working in the home. Risk assessments are carried out for all safe working practices with significant findings recorded and the action taken to minimise risks occurring. The most recent Gas, Electrical Safety certificates, including Portable Appliance Testing (PAT) were seen and records showed that all equipment is regularly checked and serviced. Certificates confirmed the passenger and stair lift have been serviced in line with the Lifting Operations and Lifting Equipment Regulations (LOLER). The fire logbook showed that the fire alarm, emergency lighting and fire fighting equipment is regularly serviced. Emergency lighting and the fire alarm system are tested weekly. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 27 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. 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 OP36 Good Practice Recommendations The positioning of the laundry facilities would benefit from being relocated to make it more accessible. The flooring needs to be made good, to ensure good infection control is maintained. Woodland Manor DS0000060707.V377170.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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). 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. 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