Care Home: Woodley Day Centre - Short Break of Care

What the care home does well Service users and their relatives expressed that they greatly value the Short Break of Care service offered at the Day Centre. Service users enjoy the `Holiday` breaks that they have and their relatives can confidently leave knowing that the person they care for will be with people they know. What has improved since the last inspection? The service has been able to provide support and give a greater number of service users and their carers a break since the last inspection process. The manager has improved some of the recruitment processes by making sure that Criminal Records Bureau checks are carried out on staff before they start working in the service. The staff have regular supervision meetings with their managers to assess and monitor their work practices. What the care home could do better: They should make sure that they can provide evidence that the recruitment process is carried out robustly as to show that staff are suitable for the roles they are employed for. CARE HOMES FOR OLDER PEOPLE Woodley Day Centre - Short Break of Care Southlake Crescent Woodley Reading Berks RG5 3QW Lead Inspector Ruth Lough Unannounced Inspection 16th November 2007 10:30 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 Woodley Day Centre - Short Break of Care DS0000064776.V353741.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. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodley Day Centre - Short Break of Care Address Southlake Crescent Woodley Reading Berks RG5 3QW 0118 9691471 0118 969 3412 See service number 64772 for email address. 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) Woodley Age Concern Mrs Ann Parr Care Home 2 Category(ies) of Dementia - over 65 years of age (2) registration, with number of places Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 12th July 2006 Brief Description of the Service: The Short Break of Care service is based in the Woodley Day Centre. It was registered as part of a programme of extending the support provided to the people using the Day Centre, who have dementia or any other significant mental health need. The service was offered originally as an alternative to the domiciliary care provision, also based in the Day Centre, where service users are offered support in their own homes. The current scale of charges are £185-£200 for two days care and overnight respite. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection process carried out to assess the quality of the service provided and the outcomes for those using it. The process included information provided in the Annual Quality Assurance Assessment, selfassessment document completed by the manager before the one- day visit to the service office. During the visit to the service the inspector took the opportunity to meet service users, relatives and staff. There have been an increasing number of service users who have used the service regularly since the last inspection process. The records, correspondence, and quality monitoring processes for two of the service users were used as to provide supporting evidence of how the service assesses and implements support to meet an individuals needs. The service was provided with surveys to distribute to service users, their relatives and staff on the commissions behalf. Three relatives and four staff returned surveys after the visit to the service. What the service does well: What has improved since the last inspection? The service has been able to provide support and give a greater number of service users and their carers a break since the last inspection process. The manager has improved some of the recruitment processes by making sure that Criminal Records Bureau checks are carried out on staff before they start working in the service. The staff have regular supervision meetings with their managers to assess and monitor their work practices. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed thoroughly before a respite stay is offered. EVIDENCE: The Statement of Purpose and Service User Guide were reviewed to see if they have the required information that should be provided to service users. The current documents were last reviewed by the manager in February 2006. The documents do give the required topics of information but some of it is now not relevent to the actual service that is provided. This is particularly in regard to how the service can be accessed and better information should be noted about the Provider and the manager. The correct contact details of the commission should also be included. Both documents give good information about the service provision, key policies and procedures and some of the contractual agreements that will be in place between the person who uses the service and the provider. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 9 Additionally they give a general booklet called Day and Night Services to all users that gives a generic overview of all the services on offer from the Woodley Day Centre. This booklet is more user friendly with the information set in sections. The manager confirmed that they were in the process of further producing a document with the key points only to be written in a easy read format. What they do well is give the reader contact details for other organisations or professionals who may be useful to the service users and their relatives. The care records for two service users who have recently used the Short Break of Care service were reviewed to see how their needs are assessed before a respite holiday break is offered. The manager did confirm that they were attempting to use the same format for the assessment of need for the Day Centre and the other registered service, Domiciliary Care as to ensure continuity of information between the services. The manager also stated that the service is more frequently offered to people who use the Day Centre, especially those who use the Sunneyside unit that offers specialist support for those with Dementia. Referrals to the service can come through the local social services or privately, the only requirement is that they reside in the geographical area of the Wokingham Unitary authority. The individuals needs are identified in the assessment records, including some medical and mental health needs, moblity and any communication difficulties. There are sections in these documents where personal information is recorded such as the responsible carer or next of kin, GP, specialist healthcare professionals and significant others who may be involved in providing support. Each service user has a personal profile where staff are able to obtain information about the individuals life history, significant people and personal interests that could assist in planning their care. This information is also partially gathered over a period of time during their use of the Day Centre services and the contact that staff try to maintain with the individuals own carer. Occassionally an assessment or reassessment takes place in the service users own home to gain an understanding of how their carers usually provide support. One individuals relative/carer had provided a very detailed summary of how the activities of the day are managed at home which did give really good instruction to how the individuals daily routine is carried out. Some of the information could be improved to include giving a greater insight of how the mental or physical health needs effects the individual, the person who supports them or their daily lives. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal care needs of the people who use the service are met and they are supported to access any medical treatment they may require during their short periods of stay. EVIDENCE: The manager provided information that there has been an increase in use of the service since the last inspection process. There are around twenty- eight individuals who regularly come and stay at the Day Centre for between two to three nights. The surveys returned from the carers and relatives who use the service stated that they thought that the individual’s needs inclusive of care and support were met. Some of the comments were, The whole centre has an ethos of sympathetic care. The staff are excellent. and The care and support given to my mother-in-law is wonderful. Another said, My daughter took my wife on the first visit and she had misgivings about leaving her mother for the first Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 11 time. But she said within seconds of their arrival her doubts disappeared because of the caring nature of the staff. The care plan records for two people who use the service were reviewed to see how staff are given instruction to assist them to meet the individuals needs. Both service users had been using the Short Break of Care recently and had been members of the Day Centre for some time. The care planning records are used for within the Day Centre service and for the periods of respite care. Care plans are written in topics that are identified as the individuals needs in the assessment process. An example of these ranges from communication, mobility, and some personal care needs. The two records reviewed were informative in some areas but for one, did not give sufficient guidance to staff of how to achieve daily activities such as getting out of bed, bathing and dressing or their night-time routine. The manager confirmed that they are able to seek healthcare support for each individual who uses the short break of care service. If required they access the services of the persons own GP and District Nurse whilst they are staying with them. Occasionally, they assist the health care professionals with monitoring health needs or have given them support to carry out minor treatments whist the person is staying in the service. The manager did state that they are looking to expand what they currently carry out as to possibly include monitoring the individuals weight, nutrition and skin condition as to assist the health professionals to meet their specific needs. The Day Centre has routine visits by a local chiropodist, and staff record in the care records any outcomes from these visits. A relative particularly praised staff for the extra mile that they went to in order to support and enable a service user to undergo a medical examination at a local hospital. The medication needs of the individual are recorded in their care plan records. Staff do not specifically note in these records what the medication has been prescribed for and for at least one service users records this highlighted that they had possibly not obtained sufficient information about the persons medical needs in the assessment process. The service users are requested to bring into the home their regular medication in the original packaging that they were supplied by the pharmacy. On arrival staff record in detail the specific medication, number and the possible side effects of the medication in a central log book. Medication is stored in a suitable secure cabinet in a central area of the Day Centre. They use their own records to note the medications given and suitable record any omissions or changes in the planned administration. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 12 Staff are provided with a medication policy and procedure that outlines their responsibilities and gives guidance on what they are able and not able to do unless they have had specific training from a health practitioner. Training for medication practices can be included in the induction programme if required and is in the regular planned training provided on a rolling programme. Two of the people who use the service regularly did say that they really enjoyed their holidays staying at the Day Centre and that staff were very friendly. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are supported to continue with their lives as the wish and are encouraged to take up new interests and activities where they are able. EVIDENCE: The Day Centre has a very busy programme of activities that are made availble to the people who use the Short Break of Care service. This includes what they may regularly attend and any specific activities that are availble during the evening and at the weekends. Staff try to obtain as much information about their interests and choices about how they wish to live from the individual, their relatives and through ongoing assessment. It was evident on discussion with some service users, staff and a relative that a variety of activities are in place, some are specific to an individuals needs and others focus on stimulating and maintaining social involvement with others. One service user was really pleased that staff had spent time with him on his previous stay to visit a local pub that he enjoyed going to when he was Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 14 younger. He also said coming to the Day Centre for a holiday break had given him a chance to meet new friends. On observation of staff with the service users it was very apparent that there was a very good understanding between them and were continually seeking new experiences or trying to maintain the individuals interests. The staff do record the involvement of the individual in the activities in a central log but not necessarily fully in the individuals care plan records. The Day Centres planned programme of activities and events includes encouraging the local community to use and visit the facilities they have available. Local schools support some of the regular events and have schemes for the pupils to become involved with visiting the centre. Service users and staff have made links with the church next door to the day centre and there are a number of social activities that are based there such as Tai Chi, Tea Dances and Line dancing that service users and members of the local community can enjoy together. The Day Centre has several minibuses that are used for transporting members and the residents of the Short Break of Care service that provides opportunities for them to go out on trips or days out to local places of interest. Service users and their carers have access to a Carers Support Worker employed to provide information guidence and seek further help for them. She is based in the Day Centre and can assist with any queries or concerns that they may have. The Day Centre is in use throughout the day and at evening times. There is a core team of staff responsible for the meal provision during these periods, both for the main services and the small unit called ‘Sunnyside’, that supports people who need a little extra help. At present service users of the centre do not have any formal imput into the menu planning for the service. However, the catering and care staff are very flexible and alternatives are provided if required. Care staff are able to access snacks between meals and at night should a resident be hungry. An individuals needs for support with meals and if they have any special dietary requirement is recorded in the care planning records. Staff do note in the daily records if they think the person has not eaten well that mealtime and alternatives are provided as snacks. Meals can be taken in the large communal room, a smaller quiet lounge and the ‘Sunnyside’ unit, depending on the needs of the individual. If the resident so wishes they can be supported to have their meals in the privacy of their bedroom. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 15 Service users expressed during the day visit to the service, that they enjoyed the food provided. One person commented that, My meals are always nice. Woodley Day Centre - Short Break of Care DS0000064776.V353741.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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user and their relatives can be confident that their concerns will be listened to and acted upon. EVIDENCE: The policies, procedures, and records for handling concerns and complaints were reviewed to assess what information is provided to service users and how well the service responds to complaints made. The systems to ensure that the people who use the service are protected from possible abuse were also reviewed. Service users are provided with the contact information of the service and given a brief statement of how the service manages any concerns or complaints in the Statement of Purpose and Service User Guide . The information does not give the expected timescales or details of the process for managing complaints, greater information is given in the full complaints procedure held in the registered services office. What could be improved is providing a named contact such as the manager or the details of the responsible person representing the provider organisation. The manager did inform the inspector that all the documents provided to service users were under review and redevelopment to make them more user friendly. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 17 The service has not been in receipt of any concerns or complaints during the last twelve months. The commission has also not been provided with any information, concerns or complaints about the service in the same period. Letters complimenting the service were available to viewed during the inspection visit. Staff are, and will be, provided with training and information about safeguarding adults from possible abuse within the induction and training programme. The service has a policy and procedure that refers to the local interagency protocols and provides staff within these documents key information about what forms abuse can take. This information is also summarised in the staff handbook. There is a whistle-blowing policy that supports staff to report concerns should they have them. Service users and their relatives confirmed that they knew how to and to whom to make a complaint or voice their concerns. Staff gave supporting information in the returned surveys that they felt that they could confidently manage any concerns raised and be able to direct the person concerned to social services and CSCI if they were unhappy with the outcomes. Woodley Day Centre - Short Break of Care DS0000064776.V353741.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): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment and facilities meet the needs of the people using the service and are kept clean, hygienic, and pleasant to live in. EVIDENCE: The facilities provided were reviewed to assess if they are suitable for the services on offer and that whilst people are resident they are given the opportunity to have privacy. The service uses two bedrooms to the rear of the building for the purposes of the holiday respite breaks. The bedrooms are equipped with sufficient furnishings and storage for the temporary stay period that the individuals would be with them. This includes wardrobe, bedside cabinet and a confortable arm chair. However, at present there is not the facilities for a lockable space for residents to keep their valuables if they so wish. To manage this staff can Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 19 take small amounts of money and items into safe keeping on a temporary basis. An assisted Wet room (shower) and separate toilet is close by to the bedrooms and there is a small sitting room with kitchenette in the same area that is exclusively for the use of the short break of care service. The bedrooms, bathroom, and sitting room can be kept secure when a resident is staying. Like the majority of the rest of the building there are key security code locks in place for the different areas as to afford safety and limit access. All of the Day Centre facilities can be made available to the people using the Short Break of Care. There is a very large area situated centrally where the main activities take place including the meals and social events. There is a slightly smaller lounge area, which is quieter and can be used by the residents if they prefer. The manager did state that the majority of the people currently using the service use the Sunnyside facilities that can accommodate a maximum of twelve people each day. This area offers a comfortable lounge dining room, kitchen facilities with access to a secure small sensory garden. The Day Centre and the facilities specifically provided for the Short Break of Care and the Sunnyside area have been developed around meeting the needs of those people who have Dementia or short-term memory. The decoration and layout in parts is designed with a more homely atmosphere and provide plenty of space for people to mobilise and walk around as they wish. The service has several toilet facilities close to the areas where people may be and they have ensured that doorways and handrails/supports are in place to allow access for those using wheel chairs and mobility aids. The service does have a small laundry room that has sufficient facilities for the volume of personal items and linen that is used when service users are resident. One relative did state that he really appreciated that his wifes clothing was returned at the end of her stay, ‘wonderfully cared for’. In the majority of the bathrooms, toilets, and kitchen and food preparation areas they have ensured that liquid soap and paper towels are available. The manager was recommended to look at changing the use of a ‘roller towel’ in the toilets close to the main public areas of the Day Centre as to reduce the possibility of cross infection within the building. Throughout there was a good standard of cleanliness and it was evident that staff responsible for maintaining the facilities, take great pride in doing so. Service users and their families did confirm in the surveys that they thought the service was always kept clean and fresh. One relative wrote, The home has a warm friendly welcoming feel about it. Woodley Day Centre - Short Break of Care DS0000064776.V353741.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): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The records do not provide that sufficient evidence that service users are protected by the recruitment practices. EVIDENCE: One relative wrote, Staff are always available to help in any way they can. I find their support a great help. The staff who responded to the commissions survey stated that they thought there was a sufficient number of staff on duty at all times and that they were provided with the necessary training to meet the service users needs. Some of the other comments expressed were, I love working here. The care that surrounds everyone is excellent, and Co- operation between staff could not be better. All said that they wished that the service continues to maintain the quality of the support it currently provides. The manager supplied information in the Annual Quality Assurance Assessment, self assessment document that the service employs fifteen parttime carers and has only used the recruitment process twice in the last year. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 21 The records for employment, staffing and the training provided for people working in the service were reviewed to assess if there is a sufficient number of experience staff employed to meet the needs of the service users. As previously stated the service is an extension of the Day Care services to provide extra support to people living in the local community. The manager stated that staff are not specifically employed to work within the Short Break of Care service, they are part of the whole day centre staff team as to maintain the ethos of continuity of care. Service users, relatives, and staff expressed that they liked this and valued the opportunities to build relationships that this offered. When service users are resident, two specific members of staff are assigned to cover the needs of the individuals at night and at times during the day, dependant on the planned activities. During the night there is usually a carer present at all times with one carer on call, sleeping in the building, who can be contacted should an emergency arise. The manager or deputy take the responsibility of being contactable out of office hours during this period should support or advice, be needed. The records of two members of staff, who have recently provided support for people using the service, were reviewed. One had been employed for a considerable length of time and one had been employed within the last four months. What was evident when looking at the records was that the information to support that the process is robustly carried out had not been fully kept. Both applicant’s had been required to complete an application form, a Criminal Records Bureau check had been carried and they had provided some evidence of any training or qualifications they had undertaken. Proof of address and identity is examined for the application for a Criminal Records Bureau check but copies of these had not been kept with the employment records that were reviewed. Insufficient evidence was available to support that the two written references had been obtained or that the manager’s decision that the applicant was suitable for the role they were to be employed for, had been recorded. A photograph and a health status declaration were not up to date for one member of staff. For one employee there was brief documented information about the induction process they were going through, but for the other nothing to note that they had been provided with any introductory training at all. The manager did confirm that there was a probationary period of six months before an employee was offered a permanent post. The recorded process for the end of the probationary period, the assessment of competencies, and the decision to employ were not seen in the one applicable employment records reviewed. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 22 Employees are required to produce copies of their training and any relevant qualification they may have. They do not at present use a formal assessment process to identify any training needs the individual staff may have this is only carried out through discussion in the supervision and general staff meetings. The manager stated that they have already recognised that they need to improve on the training planning and programme and has recently designated the specific task to one member of senior staff to take the lead. Staff who are specifically employed in the ‘Sunnyside unit are provided with training to meet the needs of people with Dementia and providing activities for people with poor mental health associated with this. Topics for safe working practices such as moving and handling and first aid, are on a rolling programme. The manager provided information in the AQAA, that 90 of staff employed, have obtained an NVQ 2 level or above. The manager was advised to implement a process that would assist in monitoring the information they obtain and keep to evidence the recruitment and employment of staff. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is run in the best interests of the service users. EVIDENCE: Comments about the service from relatives included, The staff are very caring and look after my wife in a most commendable way, and The welcome is always warm and inviting. The manager is currently responsible for the registered Short Break of Care service, Day Centre and the trial programme of Domicilary Care services. She is supported by a team of senior staff, care assistants, administrators and domestic and catering staff. The manager did state that the provider has already identified that the combined services will possibly need a specific member of staff in the future as the services develop to oversee the quality of Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 24 care provided. This position is under consultation with senior staff and the charitable organisation with details not yet finalised. Since the last inspection process the manager has continued to develop her knowledge for the role she undertakes with training including continuing with an NVQ 4. One carer wrote in the survey, The manager could not be more suportive and understanding, she sets a wonderful example. Service users are enabled to give their opinion about the service formally through a survey sent out every six months. Relatives and staff are also included in this process. The manager did confirm that they had an open door policy and welcomed comments from visitors and members at all times. This was confirmed by a relative and some of the care staff comments during the visit to the service. The manager regularly provides any feedback from service users within a monthly report to the committee of the providing charitable organisation, but as yet had not developed a method of returning the information in an appropriate format to the participants. Other quality assurrance processes do include one-to-one supervision and daily staff meetings, the outcomes of which are recorded. A programme of review of the care planning, outcomes for activities and employment records is less formal and is not necessarily recorded. The manager was advised to look at how this can be developed and used within a general assessment of the performance of the service. The service usually is not responsible for handling service users money, this is due to the nature of the length of stay each person has. If an individual uses a visiting service such as hairdressing or chiropodist this is then invoiced to them or their representative. The manager has processes in place to ensure the health and welfare of the people who use and work within the service. These include policies and procedures for safe working practices and a rolling programme of training for staff to have sufficient knowledge about the relevent key topics. Recent training has included first aid and food hygiene. Any items that should be handled and stored under the Control of Substances Hazardous to Health Regulations (COSHH) are kept safely and the required information is held both with the items and centrally with the administration team for easy access. There is a regular programme of maintanence for the building that is supported by both the charitable organisation and the local authority responsible for commissioning much of the services on offer. Records are kept of all the Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 25 routine servicing of any hot water, gas and electical systems or appliances. The water supply is regularly tested for the risk of Legionella. Staff are provided with summary of the main topics for safe working practices in their staff handbook and the people who visit and use the services are given information through posters on display in the building. Leaflets explaining some of the information are also available for them to read should they wish. Fire drills are carried out regularly and records kept of the outcomes of each process. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X X 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001, and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19, Schedules 2 and 6. Requirement That the manager should ensure that they have obtained all the required information and documents in respect to all staff employed. Timescale for action 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations That the provider and manager review and update the information in the Statement of Purpose and Service User Guide documents to ensure that the correct information can be provided to service users. That the information in the assessment process could include better detail of how the mental and physical health needs affects the individual, the person who supports them or their daily lives. That the manager develops the written instructions given in the care planning records of how staff are to achieve daily activities with the service users with particular reference to personal care and support. That staff look to improve how they can provide DS0000064776.V353741.R01.S.doc Version 5.2 Page 28 2 OP3 3 OP7 4 OP12 Woodley Day Centre - Short Break of Care 5 OP24 6 OP26 7 8 OP29 OP33 supporting evidence that they have an individual personal activity plan for each person that will meet their needs. That the manager explores how they can if required provide a lockable space in the bedrooms for service users it use for the storage of their valuables whilst they are staying in the service. That the manager reviews the current measures for hand drying in place in the communal toilets in the Day Centre as to reduce the possibility of cross infection within the building. The manager is advised to implement a process that would aid monitoring the information they obtain during the recruitment and employment process. That the provider and the manager continue to develop the processes for quality assurance monitoring and develop a method of providing any findings from these back to those who use the services and any other external stakeholders. Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Woodley Day Centre - Short Break of Care DS0000064776.V353741.R01.S.doc Version 5.2 Page 30 - 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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