Care Home: Woodlands Nursing Home

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What the care home does well The Registered Providers had provided a statement of purpose and Residents Guide to the Home, and all new Residents applying to the Home would be appropriately assessed by the Manager before an admission was arranged. The senior staff and care staff were found to be very attentive and supportive of people staying in the Home, and completed a satisfactory level of administration to support this level of care. The people spoken with also said how helpful staff were to them, which was observed during this visit to the Home. Residents were found to be appropriately protected by the Complaints procedure and the Safeguarding Adults procedure in the Home. The Home was found to be well maintained throughout. All of the administrative arrangements to ensure that the Home met the standards set by law were found to be in place. What has improved since the last inspection? The last inspection took place in August 2007. Improvements have been made to the Home in the following areas. The maintenance of the Medication Administration Record sheets was being kept at a good standard. When the Manager appointed new staff to the Home, she now ensured that the necessary information was obtained before the staff began work. The Manager now ensured that the results of all questionnaires, of Residents, and of relatives, friends and of GPs and District Nurses were published. All staff now receive all mandatory training. CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Butterley Hill Ripley Derbyshire DE5 3LW Lead Inspector Steve Smith Unannounced Inspection 6th August 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Butterley Hill Ripley Derbyshire DE5 3LW 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) 01773 744919 woodlandsch@aol.com Westwood Care Homes Limited Mollie Ann Hardy Care Home 40 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40), Physical disability (4) of places Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2007 Brief Description of the Service: The Woodlands Care Home has been purpose built and is registered for the care of 40 elderly people. The Home is registered to permit the admission of people with nursing and personal care needs. A condition of registration allows the Home to admit up to four younger adults (50 - 65 years) with physical disability needs. The Home is situated close to the town centre of Ripley. The Woodlands Care Home provides a pleasant environment for people staying in the Home and accommodation is provided on two floors. There is a passenger lift and staircase access to the first floor facilities. There are two main lounge/dining areas and a mix of single and double bedrooms are provided. Five of the single bedrooms are provided with en-suite facilities. The Home has adequate provision of assisted bath/shower facilities throughout. All bedrooms are fitted with TV points and the call/alert system operates in all areas of the Home accessed by people staying in the there. The attractive grounds are accessible to the people staying in the Home. Support services are in place with a choice of General Practitioners, and chiropody, dental, optician and other services arranged as appropriate. Information provided on 6 August 2008 stated that the fees for the Woodlands Care Home were from £350.00 to £625.00 per week, depending on the level of care and bedroom required. Details of previous inspection reports can be found at the Home, or on the Commission for Social Care Inspection’s website: www.csci.org.uk Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means that people who use the service experience Good quality outcomes. The focus of inspections, undertaken by the Commission for Social Care Inspection (CSCI), is upon outcomes for people and their views of the service provided. This process considers the Home’s capacity to meet regulatory requirements, minimum standards of practice, and focuses on aspects of service provision that needs further development. This inspection visit was unannounced and took place over a period of approximately 6 hours. In order to prepare for this visit we looked at all of the information that we have received, or asked for, since the last key inspection of the Home, which took place on 1 August 2007. This included: The ‘Annual Quality Assurance Assessment’ (AQAA). This is a document completed by the Registered Providers of the Home that focuses on how well outcomes are being met for people using the service. What the service has told us about things that have happened in the service. These are called ‘notifications’ and are legal requirements. The previous ‘Key Inspection Report’, and the results of any Other Visits that we have made to the service in the last 12 months. Relevant information from Other Organisations, and what Other People have told us about the service. Surveys returned to us by people using the service, from the relatives of those staying in the Home, and from the staff working in the Home. For this inspection of the service the Commission’s Residents questionnaire (a ‘survey’ mentioned above) was sent to 10 people staying in the Home, and 6 were returned. Ten questionnaires were also sent to staff, and 4 were returned. During this visit to the Home ‘case tracking’ was used as a system to look at the quality of the care provided. This involved the sampling of a total of four peoples records, being a cross-section of people staying in the Home. Discussions were held with those people, if they were able, together with a Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 6 number of others, about the care and services the Home provided. Their care plans and care records were also examined, and their private bedrooms and communal facilities were seen. Discussions were also held with any relatives that were visiting during this visit to the Home. In addition, discussions were held with the Manager of the Home about its general operation. Discussions were also held with staff about the arrangements for peoples care, and also about the staffs recruitment, induction, deployment, training and supervision. What the service does well: What has improved since the last inspection? What they could do better: All concerns and complaints need to be recorded, when ever they occur. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 7 The Home must be ‘inspected’ by a senior manager or Registered Provider at least one a month. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new people moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Provider had provided a good statement of purpose for the Home together with a Resident’s Guide, which informed people staying in the Home, and their relatives, of what the Home provided. The Guide was well completed, and included information from those staying in the Home on what life was like in the Home. The Residents Guide also contained information on how, if necessary, people staying could contact the Commission, the local Social Services Dept and the local Health Authority. In the Annual Quality Assurance Assessment, completed by the Manager, she wrote – ‘We have an up to date statement of purpose which reflects the changes made to our range of services offered. All residents have a Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 10 comprehensive initial assessment prior to entering the home so that both the service user and ourselves are sure we can meet their needs. All residents have individual terms and conditions. All staff are trained to be able to meet the needs of the residents. All staff have undertaken dementia and challenging behaviour training to meet the needs of the residents with dementia as well as other residents in the home. All prospective residents, families or significant others are invited to come and view the home and meet staff and discuss their requirements.’ In the questionnaire, sent out to people staying in the Home, they stated that they were very happy with the admission procedures, for example one said – ‘I am ‘very satisfied.’ Staff, who also completed a questionnaire, said that they were given good information about the care and support needs of people staying in the Home. The records of four people staying in the Home were examined during this visit and a copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, were available to examine. This ensured that peoples legal rights were protected, and was also detailed in the Annual Quality Assurance Assessment, completed by the Manager. When new people were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each person, copies of which were seen. The Manager also assessed all people sponsored by Social Services Depts. If the person was self-funding from the outset, the Manager completed her own summary of needs, which were also seen during this visit. Standard 6 does not apply to this Home. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Peoples health and personal care needs were being met, as demonstrated within care plans, and by comments made by those staying in the Home. EVIDENCE: Four records of people staying in the Home were examined, or case tracked, to ensure that suitable records were being maintained. Satisfactory initial assessment records were made by the manager, during her first visit to the potential new people in their own homes. This was found to be followed up by detailed individual plans of care and risk assessments for each person whose files were looked at. Choices and preferences of each person were also recorded in each file, and included such issues as the preference for a bath or a shower, whether the person wished to have only male or female carers to attend to their personal needs, whether staff needed to knock and await an invitation to enter the person’s bedroom, as well as information about peoples wishes about meals, etc. The files also contained information about each person’s decision making abilities, and burial wishes. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 12 However, formal six monthly review of care were not found in any of the four records examined. The Manager explained that these reviews were held, but were ‘simply’ recorded in the daily events record in each file. These records were seen, and a more extensive recording system was recommended. Good daily records were maintained by the Home’s staff, although, in the main, these records only detailed the medical needs of each person staying in the Home. Peoples care files were well organised, with different sections. Two people staying in the Home were seen to have signed their care records to indicate that they had read them. A relative (the representative) was also seen to have signed the record for their relative in the Home. However, one of the records, signed by the person staying, had 9 months between each signature. Despite this, the files did have very detailed monthly summaries contained within them. Staff were observed talking and assisting people in the lounges and dining rooms. This was seen to be done very positively, with a relaxed atmosphere, which was enjoyed by the people staying in the Home. For events that happen during a shift, nursing staff record these events in the ‘nursing handover book’. The Manager said that these event were not always recorded in peoples care files, therefore an incomplete record is kept in peoples care files. The records of peoples health needs were observed and a good record was found to be maintained. All medication and the method of distributing it to people staying in the Home was examined. This showed that a well maintained record was kept. Discussion was held with people staying in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and had a strong sense of well being. One Resident said - ‘In the main they always do things my way’ - another said – ‘Yes, as a rule staff do the things as I want.’ In the questionnaires completed by those staying in the Home, people had written that staff were good at listening and acting on what they wanted. They also recorded that staff were always available when they needed assistance. People had also recorded that they received the medical support they needed. All staff were observed to be very caring in their dealing with people in the Home, and spoke to them in a caring manner. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 13 In the Annual Quality Assurance Assessment, completed by the Manager, she had written – ‘All residents have individual care plans, with actions that are needed to be taken by staff described. The care plans also include risk assessments for tissue viability, manual handling, falls and nutrition, which are linked to clinical guidelines. Care plans are regularly reviewed and formulated with individual residents or their significant other. All care plans contain risk assessments for tissue viability – the home has a tissue viability link nurse. We also undertake nutritional risk assessments and one RGN is a dysphasia trained nurse. Policies for drugs receipt, storage, administration and disposal are in place. All staff have had training in the Liverpool Care Pathway. Two members of staff have also had palliative care training.’ Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Peoples preferred lifestyles were respected by the Home, and people were given a wholesome and appealing diet in pleasant surroundings, that enhanced their well being. EVIDENCE: People staying in the Home were asked about the activities provided. Those spoken with said that regular activities took place. They said that such activities as shopping and going out with the Activities Coordinator took place, that they sometimes went out for a meal, again with the Activities Coordinator. They also said that they did painting, which was observed on this visit to the Home, ball games were played, as well as bingo, plus a lot of other activities. Staff were also asked about the activities provided, and in addition to those already listed they said that some activities took place in the Home’s garden, that special events such as Easter and Christmas were well marked, and that individual events with each person were also undertaken. A notice in the Home indicated that Residents Meeting took place at three monthly intervals, which was also confirmed in the Manager Annual Quality Assurance Assessment. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 15 People staying in the Home said that they decided when they got up and went to bed. One person said - ‘Yes, I can go to bed when I want. I choose and staff help me, I buzz for them and they come.’ Another person said – ‘I like to have 2 baths a week, but I think you can have more if you like.’ Relatives and friends of people staying in the Home were able to visit at any time, and could always be seen in private. One person said – ‘Oh yes, I always see my daughter in my bedroom.’ The staff spoken with also said that relatives could visit at anytime. It was said that people could chose where they wanted to see their relatives, in one of the lounges, or in the person’s bedroom. People staying in the Home were able to say that the Home provided good meals and that – ‘A choice is provided at every meal … They always come and ask what I want off the menu.’ Staff also confirmed this. People and staff said that drinks and snacks were always provided between meals, and that people could also ask for additional drinks at anytime. Mealtimes were never rushed, which was witnessed during this visit to the Home. However, the menu only showed one meal provided at lunch time. Although both people staying in the Home and staff said that alternatives were available, it was recommended to the Manager that the menu should have at least two meals listed on it each day, plus the alternatives. Two member of staff was asked, when people needed assistance to managed their meal, how many people they might help at the same time. They both independently said that people were seated at tables so that they could assist two people, at the same time, if this were needed. The Manager, in the Annual Quality Assurance Assessment wrote – ‘All Residents are given a choice in routines of daily living, when to get up, where to spend their time. Open visiting hours gives freedom of when families/friends want to visit and socialise. All residents have the opportunity to discuss life history, interests and hobbies and given the opportunity to participate in activities inside and outside the home. All Residents are given the opportunity to personalise their own rooms and to bring in personal possessions. Choices are also offered at mealtimes.’ During the past 12 months the following improvements have been made in the Home – ‘We have purchased new specialist chairs which increases the opportunities for more disabled residents to spend more time in communal areas. We have increased the hours the Activities Coordinator is employed, and we have implemented Life History records for all residents. We have also commenced the formulation of life scrapbooks for residents with dementia. The Registered Provider has purchased new equipment for the kitchen to enable staff to improve timing/serving of meals especially to those who need assistance to manage their meal.’ Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Manager were addressed to meet peoples needs. The protection policies and procedures provided meant that people staying in the Home were well protected. EVIDENCE: People spoken to said that if they had a complaint to make they would tell the Manager or a senior member of staff - ‘I would tell one of the carers or Matron. They will listen and then do something. I wasn’t happy about something on day and I saw a senior member of staff who sorted it out for me.’ The Commission had not received any notice of complaint since the last visit to the Home, in August 2007. Since that visit in August 2007, the Manager had not recorded any concerns or complaints, despite what the person said at the head of this section. However, the Home had good procedures for both written and verbal complaints. The Registered Provider’s complaints procedure detailed that all complaints would be responded to by the Manager within at least 28 days. In the Annual Quality Assurance Assessment, completed by the Manager, she had written – ‘There is a clear complaints procedure which is displayed and also a copy is given to residents in the Residents Guide. (We) ensure Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 17 Residents rights are upheld and we know how to refer people to access advocacy service where appropriate.’ The Registered Provider had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy, which staff spoken to were aware of and had undergone training for. This meant that a procedure was in place to allow staff to inform the Manager of any inappropriate actions by other staff. The Registered Provider had copies of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’. The Manager confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. Staff said that they understood that people staying in the Home might, on occasion, show anger and aggression, and described the training received on the best way to resolve these situations. The Manager said that a policy was available to staff stating that they could not benefit from peoples wills, which was also understood by the staff spoken with. In the Annual Quality Assurance Assessment, completed by the Manager, she had written – ‘A Safeguarding Vulnerable Adults policies and procedures is in place, which is taught to staff. One staff member is trained to train staff in safeguarding vulnerable adults procedures by Derbyshire County Council.’ Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all people staying in the Home with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the public areas of the Home, and included many of the bedrooms of people staying in the Home. The Home was most pleasantly decorated throughout, and the lounges and dining rooms was pleasant to sit in. The bedrooms seen provided sufficient space and provision for each person staying in the Home. The Registered Provider had also provided appropriate furnishings in almost all locations seen during this visit. Bedrooms were also very pleasantly decorated, by each person, with pictures of their lives prior to moving to the Home. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 19 Toilets were easily available to everyone staying in the Home, were clearly marked, and were provided with handrails where necessary. A call system was also available throughout the Home. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. In the Annual Quality Assurance Assessment, completed by the Manager, she had written – ‘This is a well situated purpose built home, maintained to a good standard throughout, and provides a homely environment. Our garden areas are well maintained and are pleasant to sit in. We have improved the fencing to secure it for residents and upgraded the area to allow wheelchair access. The home has clearly signed toilet areas for access by residents. Specific areas of the home are designated for residents with dementia, and are adapted for their use, as individual risks may be presented. The home is clean and odour free.’ However, the following issue needed attention: Each bedroom was provided with a ‘night light’, which was of a low wattage and was left on all night. However, this light was not shaded and the bare bulb was unattractive to look at. The main lighting in each bedroom was provide by a 60 watt bulb. However, it is recommended that a 100 watt bulb be provided as the main light in a bedroom. Should the person request a bulb of a lower wattage this should be recorded within their care file. Peoples bedrooms were, in the main only provided with one comfortable chair, rather than the two recommended by the Commission. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. A good level of care staffing was provided to meet the needs of people staying in the Home. Recruitment practices were always followed when recruiting new staff, so that Residents welfare was always safeguarded. EVIDENCE: Levels of nursing and care staffing were examined for the 4 weeks beginning 23 June 2008. This showed that a good level of staffing was being provided. The Annual Quality Assurance Assessment completed by the Manager said that – ‘Staffing rotas were planned according to residents needs.’ At the time of this visit to the Home it was found that under 50 of care staff had a qualification of at least NVQ level 2 in Care; 8 of a total of 18 care staff. However, the Manager said that a further 7 staff were currently undertaking an NVQ level 2 in Care qualification. Both staff who were interviewed said that they already held an NVQ level 2 in Care. The records of two new staff employed during the past 12 months were examined to see whether the Manager had obtained all relevant information about them. It was found that all necessary information had been obtained. Care staff spoken with were able to confirm that they had been given copies of the General Social Care Council’s code of conduct and practice. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 21 The Manager said that all new staff were provided with induction and foundation training, which was confirmed by staff, and by the Manager’s Annual Quality Assurance Assessment. She also said that all care staff were provided with at least three paid days training a year, which again was confirmed by staff spoken with. In the staff questionnaires all said that induction training and ongoing training were provided at a good level. Some of the records of this training was seen. All staff also had an individual training and development assessment and profile. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were in place to ensure that Residents care was maintained at a positive standard. EVIDENCE: The Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management, and she also held a nursing qualification. The records of the monthly ‘inspections’ of the Home, carried out by a senior manager, were examined, and it was found that the Manager only had records of visits made on alternative months, for the past 12 months. The Manager was able to show the annual development plan for the Home, which was adjusted on a monthly basis. This development plan reflected the Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 23 aims and outcomes for people staying in the Home. Surveys had been undertaken with people staying in the Home on their opinions of the operation of the Home, and these had been published and posted to the relatives of those staying in the Home. The opinions of peoples families and friends or of GPs and District Nurses had also been surveyed for them to comment on how well they thought the Home was achieving goals for those staying. In the Annual Quality Assurance Assessment the Manager had said – ‘An open approach to management is used and efforts are made to increase the ways of enabling staff/service users to have their say and affect the way the service is delivered. Quality assurance and quality monitoring systems are in place and have recently been published with an annual development plan.’ The Home held a number of accounts of peoples personal money. Two of these were examined and it was seen that this was managed effectively for those staying in the Home. However, advise was given on the amount of money it was appropriate for the Home to hold for each person. The Annual Quality Assurance Assessment completed by the Manager said – ‘There are written records of all transactions where service users use their own money.’ Staff members were asked about the supervision they received from the Manager or other senior staff in the Home. They said that this was done on approximately a 2-3 monthly basis, when their own needs and the needs of the Residents, were discussed. The Manager confirmed that supervision was provided by herself or senior staff, for all care staff working in the Home. The training required by the Regulations was examined. This showed that training in Moving and Handling, Fire Safety, First Aid, Food Hygiene and Infection Control were all up to date. This was also confirmed by staff spoken with. In addition to the above areas of mandatory training, the Manager said that training was offered in Health and Safety, Dementia, Challenging Behaviour, Continence training, Nutrition, NVQs, Safeguarding Adults, Medication, the Mental Capacity Act, Catheter Care, Tissue Viability and other training. From copies of the Registered Provider’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. The Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP16 Regulation Reg. 22 Requirement All concerns and complaints made by people staying in the Home, or their relatives, must be acted upon and recorded in the complaints file in the Home. This is to ensure that an accurate record is made of all complaints and for the Registered Provider to review these and make any necessary changes to the operation of the Home seen as appropriate. The Registered Providers must ensure that the Home is inspected on an unannounced basis, at least once each month in line with the requirements listed in Regulation 26. Timescale for action 01/10/08 2. OP31 Reg. 26(3),(4) & (5) 01/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 26 No. 1. Refer to Standard OP7 Good Practice Recommendations Details of any notes kept in the nurses ‘handover book’ should all be kept in each person’s file, as appropriate. The ‘handover book’ should only be used to tell nursing staff which file to look into to see the concern or issue raised. Details of the incident or event should not be recorded in the ‘handover book’. The Manager, when formally reviewing each person’s Plan of Care and risk assessment at 6-monthly intervals, should complete a formal report, rather than simply making a note in the person’s file. Daily records of care should included more than just the medical requirements of each person staying in the Home. Those staying in the Home, or their relative (the representative), should be encouraged to sign their records at least at monthly intervals to indicate that they had read or had the record read to them. 2. OP15 At least two meals should be provided each lunch time, and be listed on the menu. The alternatives currently provided should still be made available. People who needed assistance with eating should, for example, be given both their dinner and sweet/pudding together, to avoid a long period of time elapsing between each part of the meal. People waiting to be assisted with their meal should be left in the lounge, until staff could assist them with all their meal. Where these people were slow to eat, the meal should be reheated at least twice before accepting that the person does not want to complete the meal. 3. OP24 Each bedroom should be provided with at least 2 comfortable chairs, per person in the bedroom. Should the person request only one chair, for what every reason, this should be recorded within their personal care file. The ceiling night light provided in each bedroom should be provided with a light shade, rather than the bare bulb currently provided. The main light provided in each bedroom should be of at least 100 watts. Should the person request a bulb of a lower wattage this should be recorded within their 4. OP25 Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 27 personal care file. 5. 6. OP28 OP35 Over 50 of care staff should be trained to NVQ level 2 in Care. The amounts of Residents personal allowance kept within the Home should be reduced to the amounts suggested during the visit made by the Inspector. Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlands Nursing Home DS0000066012.V369895.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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