Care Home: Woodlands Manor

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What the care home does well Woodlands Manor presented as a warm, comfortable and caring environment. The manager and her staff team were observed to interact with residents in a positive and friendly manner and were seen to treat residents with respect. Residents spoken with during the inspection were complimentary of the care they received. Feedback included; "I love it here"; "The carers are pleasant" and "The girls [staff] have always been ok with me". Other comments received via surveys included "Look after us very well" and "....My mother is very happy there." A Service User Handbook had been developed in a standard format to provide information to prospective and current service users on the service provided at Woodlands Manor and assessment and care planning systems had been established to ensure the needs of residents were identified and planned for. Residents were observed to receive visits from family members and friends during the day and service users spoken with confirmed they were supported to retain as much independence as possible. The lifestyle experienced by residents appeared relaxed and flexible and residents confirmed they could follow their preferred routines. The menu provided evidence that residents received a satisfactory diet and additional refreshments were served throughout the day. Feedback received from the people using the service and their relatives confirmed the standard of catering was good. Comments from two residents included; "The food is quite good" and "We get nice meals and there is always plenty to eat". A relative described the meals provided as "Beautiful." Staff spoken with confirmed they had access to ongoing training and development opportunities and documentary evidence of induction, safe working practice, national vocational qualifications and other relevant training was available for reference. The service continued to commission an external consultant to undertaken an annual quality assurance assessment in addition to internal quality assurance processes, to monitor the standard of service provided. Systems had also been developed to ensure an appropriate response to complaints and suspicion or evidence of abuse. What has improved since the last inspection? Since the last inspection, an electrical wiring certificate had been obtained to confirm the electrical wiring installation was safe. The Registered Manager had condensed the care planning administration and introduced a new personal care book to enable relatives and friends of residents to share information on the background, preferences, routines and support needs of the people using the service. Action had been taken to develop the programme of social activities and an `ActivitiesMission Statement 2009` had been produced to provide guidance to managers and staff on how the service should develop activities for people living with dementia. The majority of the staff team had completed training in the protection of vulnerable adults from abuse and the manager and staff spoken with during the visit demonstrated a good understanding of how to recognise and respond to suspicion or evidence of abuse. Woodlands Manor had continued to receive ongoing investment and maintenance in order to provide residents with an attractive and homely place in which to live. Action had also been taken in response to issues identified at the previous inspection. The training matrix had been updated to include details of infection control training and provided evidence that staff had access to ongoing training and development opportunities. What the care home could do better: The service should give consideration to producing the `Service User Handbook` and other information on the service in alternative formats suitable for the needs of people living with dementia. This will assist people living with dementia to understand the information more easily. Care plans should describe in detail how the health, personal and social care needs of the people using the service are to be met. This will ensure staff have all the necessary information required to provide individualised care to people living with dementia and help to safeguard the welfare of residents. Action must be taken to ensure medication administration records are correctly completed and consistently account for the receipt and administration of all prescribed medication. This will help to safeguard the health and welfare of residents and provide a clear audit trail. A medication competency assessment tool should be developed and staff should be assessed prior to administering medication and periodically thereafter. This will help to ensure staff fully understand their role and responsibilities when administering medication. Arrangements should be made to ensure activities are provided on a daily basis and to ensure community based activities and trips are provided more frequently. This will ensure the people using the service receive an effective and reliable programme of activities. The menus should be produced in a format more suitable for the needs of people living with dementia and displayed for residents to view. This will help people to understand the menu plan and assist when making meal choices. The Complaints procedure should be updated to include the name and contact details of the Care Quality Commission.A copy of the most recent fire officer`s report should be located and available for inspection to confirm the building complies with the requirements of the local fire service department. Induction Certificates should be signed off and dated by the manager to confirm staff have completed their induction and are competent and `Safe to Leave`. Documentary evidence should be obtained and available for inspection to verify that the Registered Manager has completed a National Vocational Qualification in Care at level 4. A service / test record should be obtained and available for inspection to verify that the call bell system has been routinely serviced / tested and is operating correctly. Furthermore, a service record for the fire extinguishers and emergency lighting should be obtained and available for inspection, to verify that the equipment has been serviced to the required standards. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Woodlands Manor 21-23 Chambres Road Southport Merseyside PR8 6JG     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Daniel Hamilton     Date: 0 4 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 33 Information about the care home Name of care home: Address: Woodlands Manor 21-23 Chambres Road Southport Merseyside PR8 6JG 01704544848 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Woodlands Manor Ltd care home 27 Number of places (if applicable): Under 65 Over 65 27 1 dementia old age, not falling within any other category Additional conditions: 27 0 The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum places: 1), Dementia - Code DE. The maximum number of service users who can be accommodated is: 27 Date of last inspection Brief description of the care home Woodlands Manor is a privately owned care home which is registered to provide personal care and support for 27 older people with dementia. The home is situated in a quiet residential area, not too far from the centre of Southport and all its amenities. Public transport is available close by. The premises consist of two large houses joined together by a central link and has four levels (including a basement). The basement and ground floor are serviced by a passenger lift and the main entrance is accessible via a ramp. Care Homes for Older People Page 4 of 33 Brief description of the care home The communal areas in the home consist of a dining room and two lounges, one of which is attached to a conservatory. The home is equipped with a hoist and assisted bath, shower / wet room and toilet facilities are located throughout. A call bell system with an alarm facility is fitted in each bedroom and also the communal areas. There is a large garden to the rear, which is well maintained. Off-road parking is available at the front of the premises. Weekly care home fees range from £445.00 to £455.00. Care Homes for Older People Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means that the people who use the service experience good quality outcomes. This unannounced inspection took place over one day and lasted approximately 10 hours. A partial tour of the premises took place and observations were made. Four care files and a selection of staff and service records were examined and the Registered Manager, four care staff, three visitors and 10 residents were spoken with during the visit. Reference was also made to feedback received via surveys and an Annual Quality Assurance Assessment (AQAA) which was completed by the Registered Manager. The Care Homes for Older People Page 6 of 33 AQAA enables a Registered Provider to undertake a self-assessment on the service prior to an inspection and focuses on how well outcomes are being met for people using the service and provides some numerical information about the service. What the care home does well: What has improved since the last inspection? Since the last inspection, an electrical wiring certificate had been obtained to confirm the electrical wiring installation was safe. The Registered Manager had condensed the care planning administration and introduced a new personal care book to enable relatives and friends of residents to share information on the background, preferences, routines and support needs of the people using the service. Action had been taken to develop the programme of social activities and an Activities Care Homes for Older People Page 8 of 33 Mission Statement 2009 had been produced to provide guidance to managers and staff on how the service should develop activities for people living with dementia. The majority of the staff team had completed training in the protection of vulnerable adults from abuse and the manager and staff spoken with during the visit demonstrated a good understanding of how to recognise and respond to suspicion or evidence of abuse. Woodlands Manor had continued to receive ongoing investment and maintenance in order to provide residents with an attractive and homely place in which to live. Action had also been taken in response to issues identified at the previous inspection. The training matrix had been updated to include details of infection control training and provided evidence that staff had access to ongoing training and development opportunities. What they could do better: The service should give consideration to producing the Service User Handbook and other information on the service in alternative formats suitable for the needs of people living with dementia. This will assist people living with dementia to understand the information more easily. Care plans should describe in detail how the health, personal and social care needs of the people using the service are to be met. This will ensure staff have all the necessary information required to provide individualised care to people living with dementia and help to safeguard the welfare of residents. Action must be taken to ensure medication administration records are correctly completed and consistently account for the receipt and administration of all prescribed medication. This will help to safeguard the health and welfare of residents and provide a clear audit trail. A medication competency assessment tool should be developed and staff should be assessed prior to administering medication and periodically thereafter. This will help to ensure staff fully understand their role and responsibilities when administering medication. Arrangements should be made to ensure activities are provided on a daily basis and to ensure community based activities and trips are provided more frequently. This will ensure the people using the service receive an effective and reliable programme of activities. The menus should be produced in a format more suitable for the needs of people living with dementia and displayed for residents to view. This will help people to understand the menu plan and assist when making meal choices. The Complaints procedure should be updated to include the name and contact details of the Care Quality Commission. Care Homes for Older People Page 9 of 33 A copy of the most recent fire officers report should be located and available for inspection to confirm the building complies with the requirements of the local fire service department. Induction Certificates should be signed off and dated by the manager to confirm staff have completed their induction and are competent and Safe to Leave. Documentary evidence should be obtained and available for inspection to verify that the Registered Manager has completed a National Vocational Qualification in Care at level 4. A service / test record should be obtained and available for inspection to verify that the call bell system has been routinely serviced / tested and is operating correctly. Furthermore, a service record for the fire extinguishers and emergency lighting should be obtained and available for inspection, to verify that the equipment has been serviced to the required standards. 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 set out 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. Care Homes for Older People Page 10 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this 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 are given information and have their needs assessed before deciding to move into Woodlands Manor, so that they know their care needs can be met. Evidence: A Service User Handbook had been developed in a standard format to provide prospective residents or their representatives with key information on the service provided at Woodlands Manor. The document also served as a Statement of Purpose. The registered manager reported that the document could be produced in large print and other formats subject to individual need. Feedback received from residents and their representatives via Care Home Surveys and discussion confirmed that people had received information on the service prior to moving in and written confirmation was available on files viewed. Care Homes for Older People Page 12 of 33 Evidence: The Annual Quality Assurance Assessment (AQAA) for the service detailed that a Referral and Admissions Policy had been developed for staff to reference. Three files were examined during the visit. Two were for permanent residents and one was for a respite care service user who had been admitted in the last 12 months. Both of the permanent residents had a signed copy of a Service Users Contract of Admission on file which had been developed in standard format. Files also contained a range of pre-admission, health and risk assessment information, which had been completed by senior staff and copies of social work assessments and care plans had been obtained for residents referred via care management arrangements. Records showed that the manager had written to residents or their representatives following an assessment, to confirm the service was able to meet the needs of prospective residents, the proposed admission date and room number as previously noted. At the time of the visit Woodlands Manor did not provider intermediate care. Care Homes for Older People Page 13 of 33 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this 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 health and personal care needs of the people using the service are met by staff who understand how to provide care in a manner that protects peoples privacy and dignity. Evidence: The Annual Quality Assurance Assessment (AQAA) for Woodlands Manor confirmed a policy had been developed for Individual Planning and Review and the Control, Storage, Disposal, Recording and Administration of Medicines. The AQAA also detailed that in the last 12 months a new care planning system had been developed following feedback from representatives. The files of two permanent residents and a respite care service user who had been admitted in the last 12 months were inspected during the visit. Each file was found to contain a care plan which was based on the activities of daily living model as previously noted and outlined Problem, Action and Aim. Care plans viewed did not provide sufficient information on how the specialised needs of the people using the Care Homes for Older People Page 14 of 33 Evidence: service were to be met and some information had been recorded in the wrong sections. An additional care plan was also viewed for a long-stay resident at the request of the manager and it was noted that this care plan provided more detailed information. Advice was given to the manager on the terminology used in care plans, the need for more detailed information on how the health, personal and social care needs of residents were to be met and the use of generalised pre-populated information in the aims section, to ensure the development of more person-centred care plans. Despite the absence of key information staff spoken with demonstrated awareness of the individual needs of the people they cared for and the support required. A range of supporting documentation including personal care books, risk assessments, social history, mental health assessments, daily record sheets, health and personal care records and general information had also been maintained. Records viewed provided evidence that residents had accessed a range of health care professionals subject to individual need including chiropodists, general practitioners and district nurses. Medication was dispensed by a local pharmacist using a monitored dosage system. Records of staff trained and authorised to administer medication together with a system to check the identity of residents prior to administering medication were in place as noted at the last visit. The manager reported that she continued to undertake medication audits and a file was in place to monitor and identify any issues with medication. At the time of the visit a system had not been developed to monitor the competency of staff responsible for medication and the AQAA detailed that none of the people using the service self-administered their medication. Medication checked was found to be stored correctly however advice was given to secure the medication trolley on the lower floor to the wall when not in use. A sample of Medication Administration Records (MAR) were checked during the visit. Records were generally maintained to a satisfactory standard however some issues were noted. For example, one MAR did not contain a record of whether two prescribed creams had been administered. Another handwritten MAR had not been countersigned to confirm the prescribed instructions were correct and there was no audit trail as the date the medication had been received and the initials of the person receiving the medication into the home had not been recorded. Furthermore, different codes had been used for the refusal of paracetamol 500m/g tablets for a resident and the actual balance of tablets did not correspond correctly with the MAR. There was also one occasion when a member of staff had failed to obtain a witness signature in a Care Homes for Older People Page 15 of 33 Evidence: controlled drugs register used to record Tamazepam. Staff spoken with during the visit demonstrated an awareness of the value base of social care and were observed to treat residents with respect and dignity. Residents spoken with during the inspection were complimentary of the care they received. Feedback included; I love it here; the carers are pleasant and The girls [staff] have always been ok with me. Other comments received via surveys included Look after us very well and ....My mother is very happy there. Care Homes for Older People Page 16 of 33 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Daily life, social activities and meals are flexible and varied to meet the expectations and preferences of the people using the service. Evidence: An activity timetable had been produced by the service which provided a choice of up to three activities per session each day. Information on activities was displayed on a notice board in the reception area of the home for people to view. The responsible individual (owner) had also produced an Activities Mission Statement 2009 document in order to raise awareness and provide guidance for managers and staff on the need to develop and promote sensory, neural, physical and social stimulation for people living with dementia. Since the last visit a designated member of staff had been employed who was allocated up to 8 hours per week (Tuesday for 2.5 hours and Thursday for 6 hours) to plan and coordinate a range of activities. The residents at Woodlands Manor also had access to a mini-bus which was shared between other local care homes within the Cedars Care Group. Records of trips and individual participation in activities had been Care Homes for Older People Page 17 of 33 Evidence: maintained. Records viewed highlighted that residents had participated in a range of activities including; quizzes, bingo, dominoes, memory card games, play your cards right, reading papers and magazines, armchair exercises and trips to various destinations etc. On the day of the visit a group of residents were observed to participate in baking and quiz sessions. The manager confirmed that residents would be supported to follow their religious beliefs subject to individual need and the AQAA detailed that a church service and communion was regularly facilitated for residents who wished to attend. It was noted that there had been no trips since 12th February 2009. Furthermore, although the feedback on activities was generally positive, two residents and two relatives spoken with reported that activities were not consistently provided on a daily basis and these issues should be kept under review. The home had developed policies and procedures that acknowledged the rights of residents to make choices and to maintain contact with family and friends. Residents were observed to receive visits from family members and friends throughout the day and visitors spoken with confirmed they were always made to feel welcome. Staff spoken with during the visit demonstrated a satisfactory understanding of the principles of good care practice. The manager and her staff team also acknowledged the difficulties that can be experienced when balancing the rights of residents against their duty of care, when supporting people who lack capacity due to dementia. Residents spoken with during the visit confirmed the routines in the home remained flexible and that they were able to follow their preferred routines each day. The home had produced a four-week rolling menu in a standard format which provided evidence of a choice of wholesome and nutritious meals. A copy of the menu was not on display on the day of the visit and a record of individual choices had not been completed for the lunch time. These issues were brought to the attention of the manager. Discussion with the manager confirmed the service was able to cater for different health, religious and cultural dietary requirements, subject to individual need. Additional drinks were served throughout the day and fresh fruit was available in the lounge areas for residents to eat. Meals were served in the homes dining room, which was pleasantly decorated and Care Homes for Older People Page 18 of 33 Evidence: furnished. Tables were set with tablecloths, napkins, condiments and fresh flowers. Feedback received from the people using the service and their relatives confirmed the standard of catering was good. Comments from two residents included; The food is quite good and We get nice meals and there is always plenty to eat. A relative described the meals provided as Beautiful. Care Homes for Older People Page 19 of 33 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this 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 the service are protected by the complaints and safeguarding procedures, which are understood by staff. Evidence: Woodlands Manor had developed a Complaints, Suggestions and Compliments Policy in a standard format, a copy of which had been displayed throughout the home. At the time of the visit the document was in need of review, as the details of the new regulator had not been included however a separate leaflet on the Care Quality Commission and contact details had been developed and was on display for people to view. Information on Making a Complaint and Giving Compliments had also been included in the homes Service User Handbook. The Annual Quality assurance Assessment (AQAA) for Woodlands Manor detailed that no complaints had been received by the service in the last 12 months. One anonymous complaint had been referred to the Commission during November 2008. This complaint concerned a number of care practice issues and staffing levels during the night. Given the nature of the complaint the matter was referred to Sefton Social Services Safeguarding Unit in accordance with local policies and procedures. A number of recommendations were made as part of a strategy meeting and action was taken by the manager in response. An investigation was also undertaken, the outcome of which Care Homes for Older People Page 20 of 33 Evidence: was that the allegations of inappropriate / abusive care practices could not be substantiated. No concerns or complaints were raised with the inspector during the unannounced inspection by the people using the service or their representatives. Residents spoken with confirmed they were confident that any concerns would be listened to and acted upon. For example, a resident reported; I have no concerns about this place and a relative stated One on one care is very good. Staff very attentive and listen to problems.... The home had policies and procedures in place to Protect Vulnerable Adults from abuse. The policies included an Avoidance of Abuse and a Whistle blowing procedure. A copy of the local authority adult protection procedures for the City of Liverpool and Borough of Sefton was also available for reference. Training records showed that the majority of the staff team had completed training in the protection of vulnerable adults to date and the manager and staff spoken with during the visit demonstrated a good understanding of how to recognise and respond to suspicion or evidence of abuse. Care Homes for Older People Page 21 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this 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 standard of the environment within Woodlands Manor is continually improving providing residents with an attractive and homely place to live. Evidence: Woodlands Manor had access to two full-time handy persons who were responsible for the general maintenance and repair of the premises together with other local care homes within the organisation. Contractors were also hired for major and specialised work as and when required. Job sheets were in place to record work in need of attention and an internal and external maintenance plan had been developed. Monthly Health and Safety audits were also undertaken as noted at the last inspection. The home is not purpose built for people with dementia - as the bedrooms are situated over three floors (ground, first and second floors) and are not therefore immediately accessible. Please refer to the Brief Description of the Service section for more information on the premises. The manager reported that the owner is currently exploring the possibility of extending the rear of the premises in order to improve the environment both internally and externally, subject to planning approval. Care Homes for Older People Page 22 of 33 Evidence: The Annual Quality Assurance Assessment for the Service (AQAA) confirmed that the premises had continued to receive ongoing investment, maintenance and refurbishment since the last visit. In the last 12 months the hall, stair and landing carpets on the first, second and third floor have been replaced and eight bedrooms have been refurbished and redecorated. Furthermore, the lounge had been refurbished and the dining room redecorated and 15 chairs and a plasma TV purchased. Residents spoken with confirmed that they were generally satisfied with the standard of accommodation provided and rooms viewed had been personalised with photographs, ornaments and various memorabilia as previously noted. A partial tour of the premises was undertaken during the inspection. Overall, areas within Woodlands Manor appeared to be maintained to a satisfactory standard and the external grounds were tidy and attractive. Two part-time domestic staff and a laundry assistant were employed and infection control policies and procedures had been developed for staff to reference. Training records detailed that 19 staff (including the manager) had completed infection control training and areas viewed appeared generally clean and hygienic. Records confirmed that the service had received visits from both an environmental health and fire officer since the last visit. No contraventions or recommendations were identified in the environmental health officers report however a copy of the fire officers report could not be located. Care Homes for Older People Page 23 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements, recruitment and training and development opportunities ensure that people are cared for and supported safely. Evidence: On the day of the visit the home was accommodating 21 permanent and one respite resident. Examination of rotas and direct observation confirmed the service was being staffed with one senior and three carers from 8.00 am until 2.00 pm. From 2.00 pm until 8.00pm one senior and two carers were on duty. During the night, three waking night staff were on duty. The manager continued to work Monday to Friday each week or as required by the service and ancillary staff were employed for catering, cleaning and laundry duties. The manager confirmed that she continued to monitor and review the needs of residents and staffing levels in Woodlands Manor in accordance with guidance issued by the Department of Health. Comments received from the people using the service and their representatives were generally positive regarding the support provided by staff. Comments included: On the whole the staff are approachable and helpful, We have very good staff and The staff have always been very good to me. Care Homes for Older People Page 24 of 33 Evidence: The Annual Quality Assurance Assessment (AQAA) for Woodlands Manor detailed that the service employed 19 care staff and this was confirmed in discussion with the manager. The training matrix dated 3/06/09 highlighted that 9 care staff (47.36 ) had completed a National Vocational Qualification at level 2 or above in Care and a further three staff had commenced the training. Once the outstanding staff have completed the training 12 care staff (63.16 ) will have completed the training. The AQAA confirmed that the service had a policy on recruitment and employment in place as previously noted. The manager reported that three staff had commenced employment since the last visit. The recruitment files of the three new employees were viewed and all the necessary records required under the Care Home Regulations 2001 had been obtained. Recruitment records were well maintained and provided evidence of safe and robust recruitment practice. Personnel files contained copies of progress logs and certification to confirm new staff received inductions that met the requirements of Skills for Care. Advice was given to the manager regarding the need to ensure inductions were completed within 12 weeks of commencing employment as two certificates of completion had not been dated. The AQAA for Woodlands Manor detailed that a staff training matrix had been developed and each member of staff had a training plan. The majority of training was accessed via the Sefton partnership or commissioned via an external training organisation. Since the last visit a staff training room had been developed within Woodlands Manor. The training matrix was viewed during the inspection and highlighted that staff had access to a range of training including induction, safe working practice, protection of vulnerable adults and other training relevant to their role and responsibilities. No significant gaps were noted for mandatory training topics however gaps in other training areas were noted. The manager confirmed that action was being taken to ensure all staff completed the necessary training for their roles and dates of forthcoming training had been entered on to the matrix. Since the last inspection six staff (including the manager) had also completed equality and diversity training. Staff spoken with during the inspection reported that they had only completed basic awareness training in dementia care. The manager reported that staff were being nominated to attend a distance learning dementia course and that Yesterday, Today and Tomorrow training, developed by the Alzheimers society, was scheduled to be rolled out to all staff during July 2009. Care Homes for Older People Page 25 of 33 Care Homes for Older People Page 26 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Woodlands Manor is being run in the best interest of the people using the service so that their welfare is promoted and protected. Evidence: Mrs Lyndsey Floyd is registered with the Care Quality Commission as the manager of Woodlands Manor and has managed the service since approximately June 2005. Prior to her appointment, Mrs Floyd worked as a deputy manager in another home within the Cedars Care Group. Documentary evidence was viewed which confirmed the manager had completed the National Vocational Qualification (NVQ) level 4 Registered Managers Award. The manager reported that she had also completed a National Vocational Qualification at level 4 in Care however the certificate could not be located at the time of the inspection and no details had been recorded on the training matrix. Care Homes for Older People Page 27 of 33 Evidence: Training records viewed confirmed the manager had undertaken a range of training in the last 12 months which included: in-house management training, moving and handling, first aid, abuse, equality and diversity, oral health, optical awareness, mental capacity and stress management. Feedback received from staff, residents and their representatives confirmed the manager was approachable and supportive and staff reported that they had access to appraisals and supervisions and attended team meetings periodically. Prior to the inspection the manager completed an annual quality assurance assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us numerical information about the service. Overall, the AQAA was detailed and provided supporting evidence to illustrate what the service does well, how it has improved in the last year and plans for improvement in the next 12 months. The Registered Provider continued to commission an external consultant undertaken an annual quality assurance assessment to monitor the standard of service provided. This was last completed during June 2008. Records were also available to confirm the responsible individual (owner) had undertaken monthly visits and produced reports in accordance with Regulation 26 of the Care Home Regulations 2001. The manager reported that the service continued to distribute surveys to the people using the service or their representatives throughout the year in order to obtain additional feedback on the service provided. The results had been summarised and were available in reception for people to view and a suggestion box had been sited in the reception area of the home to encourage residents to share their views privately. No residents meetings had taken place since the last visit however review meetings were organised with relatives periodically. The manager confirmed that she did not act as an appointee and reported that all the residents looked after their financial affairs independently or with support from family members or personal representatives as previously noted. The organisations head office continued to coordinate the administration tasks associated with invoicing and administering fees. The manager looked after the personal spending money of two residents and the annual quality assurance assessment (AQAA) confirmed money was stored in a safe and receipts and records of expenditure maintained. Examination of the AQAA confirmed that health and safety policies and procedures were in place and that equipment in Woodlands Manor had been routinely serviced and maintained. Electrical wiring, portable appliance testing, fire extinguishers, gas safety Care Homes for Older People Page 28 of 33 Evidence: and fire alarm service records were selected to view during the visit and the following issues were noted. The AQAA detailed that the emergency call equipment had been serviced in March 2009 however the last certificate for the call system was dated 9th October 2006. Furthermore, the manager reported that the fire extinguishers had been tested during April 2009 however a certificate had not yet been received and the fire alarm service sheet dated 30/10/08 did not specify whether the emergency lights had been tested as part of the service. Fire records were also checked during the visit. Records provided evidence that the fire alarm system had been tested on a weekly basis and that monthly visual checks of the fire extinguishers and testing of the emergency lighting had been undertaken. Since the last inspection the fire risk assessment had been reviewed and records confirmed day and night staff had received fire instruction training periodically. Care Homes for Older People Page 29 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 30 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Action should be taken to 04/07/2009 ensure medication administration records are correctly completed and consistently account for the receipt and administration of all prescribed medication. This will help to safeguard the health and welfare of residents and provide a clear audit trail. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The service should give consideration to producing the Service User Handbook and other information on the service in alternative formats suitable for the needs of people living with dementia. This will assist people living with dementia to understand the information more easily. Care plans should describe in detail how the health, personal and social care needs of the people using the service are to be met. This will ensure staff have all the necessary information required to provide individualised 2 7 Care Homes for Older People Page 31 of 33 care to people living with dementia and help to safeguard the welfare of residents. 3 9 A medication competency assessment tool should be developed and staff should be assessed prior to administering medication and periodically thereafter. This will help to ensure staff fully understand their role and responsibilities when administering medication. Arrangements should be made to ensure activities are provided on a daily basis and to ensure community based activities and trips are provided more frequently. This will ensure the people using the service receive an effective and reliable programme of activities. The menus should be produced in a format more suitable for the needs of people living with dementia and displayed for residents to view. This will help people to understand the menu plan and assist when making meal choices. The Complaints procedure should be updated to include the name and contact details of the Care Quality Commission. A copy of the most recent fire officers report should be located and available for inspection to confirm the building complies with the requirements of the local fire service department. Documentary evidence should be obtained and available for inspection to verify that the Registered Manager has completed a National Vocational Qualification in Care at level 4. A service record for the fire extinguishers and emergency lighting should be obtained and available for inspection, to verify that the equipment has been serviced to the required standards. A service / test record should be obtained and available for inspection to verify that the call bell system has been routinely serviced / tested and is operating correctly. 4 12 5 15 6 7 16 19 8 31 9 38 10 38 Care Homes for Older People Page 32 of 33 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. 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