Care Home: Woodleigh Christian Care Home

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What the care home does well Peoples needs are assessed before they move into the home so that staff know how to meet their needs. People are offered a range of information before they choose to move into the home. We found the computerised care plans easy to navigate, person centred and they included information that was important to the individual and showed how individual choices around daily living were being maintained. The care plans contained information on what care support is needed and how staff needed to deliver the care. There were also risk assessments for falls, pressure care and nutrition and information on any equipment needed to manage the risks. Care plans to show staff how to minimise the risks had been implemented and we observed that the care plans had been put into practice for the three people we case tracked, with the equipment detailed in their care plans being found in place and being used appropriately. When we asked staff what the home did well they said, "I believe we are delivering the best care available", "We always try to provide the best level of care", "Care is very individual and personal and there are good relationships between people that live here, their relatives and the staff." The home has a weekly activity plan for in-house activities and a monthly activity plan for external entertainers and planned events. There are also weekly trips out and the home are planning a holiday for some of the people living in the home for later in the year. What has improved since the last inspection? The activity organiser has implemented personal profiles and life history stories, which give clear information on peoples likes and dislikes as well as their hopes and aspirations. They told us that they are planning to further develop these with the aim of supporting people living in the home to achieve goals in the future. The home has a team leader for individual areas of the staff team and this includes a leader for the activities, catering, nursing, training and administration. The team leaders and the management team have an away day four times a year and they use this for planning further improvements for the home. Each leader gives a presentation on what they are achieving and discussions are held on the plans for the future on the home. Staff have been nominated for the Great East Midlands Care Awards and four members of staff managed to reach the finals. These awards are aimed at recognising people who work in the care industry. The home is currently undergoing an extension project, which will provide more communal living space as well as more bedrooms. The new bedrooms will be used to provide single rooms so that people in shared bedrooms have the opportunity to move into a single room. There is also going to be a new kitchen and treatment room and some current bedrooms will be improved with the installation of en-suite facilities. What the care home could do better: Staff files should contain an up to date photograph of the member of staff. Any hand written entries on the Medication Administration Record must be signed by the person making the entry and also witnessed by a second member of staff to show that the entry is correct. Key inspection report Care homes for older people Name: Address: Woodleigh Christian Care Home Norfolk Drive Mansfield Nottinghamshire NG19 7AG     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Lynda Dyer     Date: 0 8 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. Care Homes for Older People Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Woodleigh Christian Care Home Norfolk Drive Mansfield Nottinghamshire NG19 7AG 01623420459 01623460381 sam@woodleighcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Dr Gail Margaret Walton,Mr John Richard Walton Name of registered manager (if applicable) Samantha Eves Type of registration: Number of places registered: care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 40. The registered person may provide the following category of service only: Care home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category:- Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Woodleigh Christian Care Home is situated 100 yards from Chesterfield Road, which has a bus route into Mansfield town centre, approximately half a mile away. The property is an attractive two-storey, Victorian building, which has been extended in the last 10 years. It provides nursing and residential care for up to 40 older people in single and twin bedded rooms the majority of which have en-suite facilities. There is a Care Homes for Older People Page 4 of 29 Over 65 40 0 Brief description of the care home shaft lift to assist independent access between floors. There are three lounges and two separate dining rooms. A well maintained garden provides a safe outdoor area and is accessible to all of the residents, there are also car-parking facilities on site. The home is run on Christian principles but accepts people from other religions and cultures. The fees currently charged at the home range from £450 - £750 per week plus additional nursing rate when applicable. The fees charged at the home do not include services such as hairdressing, podiatry services and newspapers. Care Homes for Older People Page 5 of 29 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: three star excellent 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 last time we visited this service was November 6th 2007. The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people who live at the home and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. We as it appears throughout the Inspection Report refers to The Care Quality Commission. We have introduced a new way of working with owners and managers. We ask them to fill in a document that gives information on how well their service provides for the needs of the people who live there and how they can and intend to improve their service, this is called an Annual Quality Assurance Assessment (AQAA). Care Homes for Older People Page 6 of 29 We received the AQAA back from the manager in good time, the form was well completed and it helped us to plan our visit and to decide what areas to look at. We also sent out surveys called, have your say, to people who live in the home, staff that work there, health professionals and visitors. This meant we could get an idea of what people thought about the way the service was run. We had twenty one completed surveys back and we have included some of the comments in this report. We have not included comments that could identify the writer as we want people to feel they can be open about the way they feel the service is run. We reviewed all of the information we have received about the service since we last visited and we considered this in planning the visit and deciding what areas to look at. The main method of inspection we use is called case tracking, which involved us choosing three people who live at the service and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. One inspector carried out an unannounced site visit to the Home, which took place over 6 hours. The Registered Manager and the Registered Provider assisted us during the site visit to the service. We spoke with four members of staff and six people who live in the home to form an opinion about the quality of the service being provided to people living at the home and we have included some of their comments in this report. We read documents as part of this visit and medication was inspected to form an opinion about the health and safety of people who live at the service. We observed people during lunch and in other communal areas to see how staff interacted with the people that live there. A partial tour of the building was undertaken which included peoples bedrooms and communal areas they frequent to make sure that the environment is homely and safe and we read documents as part of this visit to form an opinion about the health and safety of people who use at the service. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: Care Homes for Older People Page 8 of 29 Staff files should contain an up to date photograph of the member of staff. Any hand written entries on the Medication Administration Record must be signed by the person making the entry and also witnessed by a second member of staff to show that the entry is correct. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 29 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 10 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed before they move into the home so that staff know how to meet their needs. People are offered a range of information before they choose to move into the home Evidence: The manager told us in the homes Annual Quality Assurance Assessment (AQAA) that an assessment is always done before admission by a fully trained nurse and/or the qualified home manager. They told us that the written assessment is undertaken including other professionals where appropriate and that this assessment takes account of additional needs for funding, staffing and equipment. We spoke with the person most recently admitted to the home and they described the admission process and how the manager had visited their home and completed an assessment of their needs. We looked at their care records, which are computerised and these clearly showed that an assessment of needs was carried out prior to them Care Homes for Older People Page 11 of 29 Evidence: moving into the home. We spoke with staff about this persons admission and they confirmed that an assessment had been carried out by the manager and that they had been given information about the person prior to admission so that they knew what care needed to be delivered. We received surveys back from people living in the home and these told us that people had been given enough information about the home before deciding if this was the right place for them. When we spoke with the most recent admission to the home, they told us that their family had been able to visit the home and look around and that they had been given information about the services the home offered. We looked at the information that the home gives to people who express an interest in moving in. This is very comprehensive and user friendly and includes a DVD presentation, a photobook and a full colour newsletter with details of what has happened in the home and what is planned for the future. There is a service user guide, which is available in a range of formats such as large print and braille. The guide contains photographs, some experiences of the home written by people who live there, facilities available and details of care that is delivered. The home also has a website www.woodleighcare.co.uk and this gives a detailed description of the service and what it can offer. One external health professional sent a completed survey back to us and they told us that the homes assessment arrangements usually ensured that accurate information was gathered and the right service was planned for people. When we asked what the home did well, they said, Planned care. The home does not provide intermediate care and so standard 6 does not apply. Care Homes for Older People Page 12 of 29 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. People living in the home have up to date and relevant care plans to enable staff to deliver the appropriate individual care and people are happy with the care they receive. Medication procedures are generally safe. Evidence: The manager told us in the homes Annual Quality Assurance Assessment (AQAA) that peoples individual care plans detail their health care needs and preferences and that a computerised care planning system ensures that reviews and evaluations are prompted when they are due. The manager told us that there is a high level of multidisciplinary input into plans of care, with the home having strong links with community specialist nurses and other health professionals, who provide advice, support and training. They also told us that they have reviewed and updated medicines policies and that regular audits are carried out to identify problems with drug administration. We looked at the care plans of three people living in the home. The plans are computerised and staff told us that they had been trained to use the care plans and that they were accessible, easy to use and that they were used as a working tool to Care Homes for Older People Page 13 of 29 Evidence: plan care delivery. We found the care plans to be easy to navigate, person centred and included information that was important to the individual and showed how choices around daily living were being maintained. The plans contained information on what care support is needed and how staff needed to deliver the care. There were also risk assessments for falls, pressure care and nutrition and information on equipment needed to manage the risks. Action plans to show staff how to minimise the risks had been implemented and we observed that these plans had been put into practice for the three people we case tracked, with the equipment detailed in their care plans being found in place and being used appropriately. The care plans gave clear evidence of people receiving care from external health professionals and people living in the home told us how staff supported them to do this. There was evidence of the care plans being reviewed regularly, which means that the care being delivered is up to date and relevant. When we asked people living in the home what the home did well, one person said, Always get a GP if I am not well. The Mental Capacity Act had been introduced to the care plans that we viewed and we spoke with staff about the homes recent reponse following a Deprivation of Liberty assessment having to be made one person living in the home. This evidence showed that the home had managed the safeguards well and there had been a positive outcome for the person it related to. These acts are aimed at protecting peoples rights and choices. When we asked staff what the home did well they said, I believe we are delivering the best care available, We always try to provide the best level of care, Care is very individual and personal and there are good relationships between people that live here, their relatives and the staff. People living in the home told us that they received the care and support they needed and they also told us that the home made sure they received medical care when it was needed. We looked at the homes medication storage and administration procedures and we found that some handwritten entries on the Medication Administration Record had not been witnessed by a second member of staff. However we found that the medication was being managed well by the trained nurses. The nurse spoken with was Care Homes for Older People Page 14 of 29 Evidence: knowledgeable about the medicines and was aware of the requirements for the safe receipt, storage and disposal of medicines. We also observed the nurse administering prescribed medicines and saw that they were following safe procedures. An external health professional told us that the home always supported people to manage their own medication or to manage it correctly where this was not possible. Each person living in the home has a dignity care plan and there are dignity champions within the care and nursing teams. There is also annual training as well as discussions during induction and supervisions to keep dignity high on the agenda in the practice of the staff throughout all their work. We spoke with people living in the home and they told us that staff respected their privacy and their dignity and we observed staff knocking on peoples bedroom doors before entering, to maintain privacy. An external health professional told us that the home always respected peoples privacy and dignity. Care Homes for Older People Page 15 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A wide range of activities is offered to residents which allows them to make a choice of the social activities. The dietary needs of the residents are being met. Residents are encouraged to maintain links with the family and community. Evidence: The manager told us in the homes Annual Quality Assurance Assessment (AQAA) that people living in the home are consulted about activities provision and facilitate feedback, adjusting the service to suit their aspirations. They told us that the home provides an extensive and varied activity program with several things going on every day of the week and that the home has strong community links, with local schools, music groups, choirs and churches. The manager also told us that the home offers a range of choices at meal times, with locally sourced fresh food and menus that are different every week. An external health professional told us that the home always helped people living there to live the life they chose. When we asked relatives what the home did well, one relative said, Trips out, holidays, social events and parties. Another said, The food is good. Care Homes for Older People Page 16 of 29 Evidence: Relatives told us that the home helped their relative to keep in touch with them and kept them up to date with important issues. When we asked staff what the home did well they said, Meets individual needs well, Places importance on the spiritual wellbeing of staff and people living in the homeand Provides a variety of daily activities and social outings, into the community and encourages strong positive relationships with family and friends A group of people with an interest in the home have been formed and are called, The friends of Woodleigh Christian care home. They meet regularly and help with fund raising and deciding where the raised funds can be best spent. People living in the home told us that they got to take part in activities arranged by the home. When we asked people living in the home what the home did well, one person said, Lots of activities. Another person said, Church services and communion. Teas are good and family are always welcome. We spoke with the activity organiser and they showed us evidence of activities carried out with the people living in the home. We saw that people living in the home are consulted on what individual or group activities they want to take part in and that detailed records are kept of activities they have been involved in. The activity organiser has implemented personal profiles and life history stories, which give clear information on peoples likes and dislikes as well as their hopes and aspirations. They told us that they are planning to further develop these with the aim of supporting people living in the home to achieve goals in the future. The home has a weekly activity plan for in-house activities and a monthly activity plan for external entertainers and planned events. There are also weekly trips out and the home are planning a holiday for some of the people living in the home for later in the year. One person living in the home has been supported to have their own internet connection and the computer equipment they have in place is designed for people with a sight impairment. Staff told us that this had helped them to retain their links with the community as well as forge new ones. Care Homes for Older People Page 17 of 29 Evidence: We observed the lunch period in the home and we found this to be a relaxed and enjoyable occasion. A menu was displayed on each dining table and detailed the choices available for that day. The meal looked nutritious and appetising and we spoke with people living in the home and they told us that the food was good and that there was a choice every meal time. Detailed nutrition plans are in place for people living in the home to ensure their nutritional needs are responded to and met. Care Homes for Older People Page 18 of 29 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 excellent 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 feel able to raise concerns and complaints and can be confident that the manager will act on them. Staff know how to safeguard people living in the home from abuse. Evidence: The manager told us in the homes Annual Quality Assurance Assessment (AQAA) that the complaints procedure is included in every contract, is on show in the foyer, along with comment cards and also available in a range of different formats. They told us that they have positive, collaborative relationships with people living in the home and their families and representatives that encourages open communication. They also told us that training on abuse protection is in place and that a whistle blowing policy is in place and that staff are trained in how to use it. We have not received any complaints about the service since we last visited. The manager told us that the home has received two complaints since the last inspection, one was upheld and one was partially upheld. We looked at the complaints file and we saw that the complaints had been addressed and the home had taken action to minimise the risk of a complaint of this nature occurring in the future. The home had also made a referral to an external professional body in order that they could ascertain if the home had acted appropriately and if any improvement could be made. Relatives of people living in the home told us that they knew how to make a complaint Care Homes for Older People Page 19 of 29 Evidence: and that the home had responded appropriately if they had raised any concerns. People living in the home told us that they knew who to speak with if they were not happy and staff told us that they knew what to do if people living in the home, or their relatives, raised a concern with them. One person living in the home said, I am quite satisfied, I have no complaints. The home has the current local safeguarding vulnerable adults procedures in place in the home. Training records showed that care staff have received training in relation to Safeguarding Vulnerable Adults and staff spoken with were able detail appropriate actions to be taken should they suspect abuse was happening. Care Homes for Older People Page 20 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good housekeeping procedures provide people with clean, safe and homely surroundings in which to live. Evidence: The manager told us in the homes Annual Quality Assurance Assessment (AQAA) that the maintenance programme is extensive, well documented and based on sound building service engineering principles with the home being able to meet the needs of the range of people catered for. They also told us that there are well established infection control procedures with all staff completing training in this. A variety of communal space is available for people living in the home to use, which includes a number of different dining and lounge rooms together with quiet areas, in which people living in the home can receive family and friends as they wish. The home is currently undergoing an extension project, which will provide more communal living space as well as more bedrooms. The new bedrooms will be used to provide single rooms so that people in shared bedrooms have the opportunity to move into a single room. There is also going to be a new kitchen and treatment room and some current bedrooms will be improved with the installation of en-suite facilities. We found the home to be clean and well maintained on the day of the inspection and Care Homes for Older People Page 21 of 29 Evidence: people living in the home told us that it was always clean and fresh. When we asked people living in the home what the home did well, one person said, It is welcoming and friendly. When we asked staff what the home did well they said, We are improving facilities at present including increasing en-suite facilities. The home has a range of up to date specialist equipment and adaptations to meet the individual needs of the people living there and these are maintained effectively. The home has infection control policies in place and staff records showed that staff are trained in how to put these policies into practice. We observed staff following procedures in order to minimise the spread of infection and areas in the home that are at high risk of the spread of infection, such as toilets have had non contact light switches installed. Care Homes for Older People Page 22 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home operates a safe staff recruitment process and staff are trained effectively in supporting people living there. Evidence: The manager told us in the homes Annual Quality Assurance Assessment (AQAA) that extra staff are employed at breakfast and lunch times and to cover the activities and weekly outings. They told us that the recruitment process is thorough, with all current staff having the required checks in place. They also told us that all new staff receive Skills for Care Induction training and that staff receive appropriate training through the year. An external health professional told us that the manager and staff always had the right skills and experience to support peoples health and social care needs. One relative told us, The home is well staffed. Staff recruitment files showed evidence of all the required checks being carried out prior to staff commencing employment in the home. Staff also told us that they had to wait for the required checks to be made before they commenced working in the home. We saw evidence of staff being given a thorough induction when they started working Care Homes for Older People Page 23 of 29 Evidence: in the home and one member of staff told us that they were given an induction and were supervised for a period of time until they felt confident in their role. We spoke with four members of staff on the day of the inspection and they were all knowledgeable about the people they were supporting and about the policies of the home. They showed enthusiasm and dedication for their role in the home and one member of staff said, We all work well as a team and enjoy working here. The morale is high and we are quick to spot if something is not right with someone who lives here. We act to prevent rather than try to cure. Staff told us that they were given training above and beyond the mandatory training and we saw that staff training records were being well maintained on the computerised system, with a clear audit available so that the manager can identify training needs. When we asked staff what the home did well they said, I have worked here for many years and it feels like a second home to me. I could not be happier, Supports staff well, I feel confident and well supported in my role and am regularly encouraged to take opportunities to develop my role within the home, We work well as a team with a good skill mix and we are always open to change within our roles. People living in the home told us that the staff were usually available when they needed them and that they listened and acted on what they said. When we asked people living in the home what the home did well, they said, Lots of staff who work hard, Staff are always helpful and There are plenty of staff who work very hard. The home has a team leader for individual areas of the staff team and this includes a leader for the activities, catering, nursing, training and administration. The team leaders and the management team have an away day four times a year and they use this for planning improvements for the home. Each leader gives a presentation on what they are achieving and discussions are held on the plans for the future in the home. Staff have been nominated for the Great East Midlands Care Awards and four members of staff managed to reach the finals. These awards are aimed at recognising people who work in the care industry. Care Homes for Older People Page 24 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is evidence that the home is run in the best interests of the people that live there and that the manager supports a team of staff to deliver safe and effective care. People using the service are given the opportunity to express their views and opinions in the running of the care home and the home has effective methods of measuring the quality of service provision. Evidence: The manager completed the homes Annual Quality Assurance Assessment (AQAA) with clear and accurate information and sent it to us when we asked for it. The AQAA showed that the home continues to improve and that the manager and provider know what improvements can still be made. The manager holds the required qualifications and attends regular training to ensure she keeps up to date with new ways of working and changes in legislation. We spoke with people living in the home and with staff and it was clear that people Care Homes for Older People Page 25 of 29 Evidence: felt that the manager was supportive and approachable with a transparent method of managing the home. When we asked staff what the home did well they said, The management team are very approachable and understanding, Creates the best care and achieves the goals that are set, Woodleigh is a warm and friendly care home and the staff and management all work well together as a team Comprehensive policies and procedures are available to staff and they are updated annually. Documentation that we asked to see was readily accessible and very well organised. The home has achieved Investors in People and has been accredited to Quality Management Systems ISO9001 following a thorough external inspection and audit of their systems that took place over six months months. There is a range of methods of measuring the quality of the service delivered. There are regular discussions between staff, the manager and people living in the home, with questionnaires regularly being sent to people living in the home, their relatives, staff and external professionals. The results of these questionnaires are collated and an action plan produced. The results and action plan are displayed for people to see and we saw the results of the most recent survey conducted. There are regular internal audits in all areas of the home, with clear actions and accountabilities as a result of the outcomes of the audits. There are regular meetings held for people living in the home and Care to Comment cards are displayed in the foyer. The registered provider is actively involved in the day to day running of the home and performs spot checks to ensure the quality of service provision is maintained to a high standard. This includes regular monitoring of maintenance on systems in the home including fire checks and electrical testing. We looked at the personal spending money that the home holds for two people living there and we found that they were being managed appropriately. Care Homes for Older People Page 26 of 29 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 27 of 29 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 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 9 Any hand written entries on the Medication Administration Record must be signed by the person making the entry and also witnessed by a second member of staff to show that the entry is correct. Staff files should contain an up to date photograph of the member of staff. 2 29 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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