Care Home: Woodthorne

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What the care home does well We found that Woodthorne offers a genuine commitment to care with a competent, yet open and personable approach, which reflects the homeliness of a confident relationship between carer and service user: "I have been very well looked after here, and I am aware of other homes and the quality of care is as good as it gets. My daughter is in your profession and she agrees with me", "I like it here, its lovely, all the staff are very, very nice, and my key worker helps me all the time". From examination of care records we established that there was an effective assessment, detailed care planning and review of individual needs, which are meaningful and robust, in formulating a good standard of care. When we discussed the quality of care with residents and visitors, it was made clear that they appreciated this highly personable attitude and approach to care. The housekeeping, administrative and support services have all contribute to the team approach, and are recognised by the management for their efforts. We considered that the overall management style demonstrated a solid approach in maintaining an environment conducive to the care of the elderly. There is a regular appraisal and review process of facilities and services, to maintain that environment by the senior care management and Providers. What has improved since the last inspection? We found an improvement in the pre-admission assessment process, with relatives and prospective residents being more involved, and that a communication record is kept in all care files, confirming that relatives are actively involved in the planning of care. We examined and confirmed that care files have been re-organised to provide a more user-friendly working document. Our discussions with staff confirmed an improvement in the standard of the Induction programme. Information gathered from the AQAA and discussed during our inspection included improvements in regular staff supervision and an updated training plan, this was found to be true. CARE HOMES FOR OLDER PEOPLE Woodthorne 12 Thompson Street Willenhall West Midlands WV13 1SY Lead Inspector Keith Jones Key Unannounced Inspection 20th 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 Woodthorne DS0000033323.V367806.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. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodthorne Address 12 Thompson Street Willenhall West Midlands WV13 1SY 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) 01902 606365 01902 606365 Miss Satwant Chahal Miss Satwant Chahal Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2007 Brief Description of the Service: Woodthorne care home is providing personal care and accommodation for 21 older people. The home is a Victorian detached property situated on the outskirts of Willenhall. It is close to local amenities. The home has a single storey extension to the side of the existing property, and provides eleven single rooms and five double rooms, with wash hand basins in all the rooms. In addition to the lounge and dining area, there is a very pleasant conservatory, which overlooks an attractive patio and garden. There is ample car parking space. Woodthorne is well suited to meet the needs of the stated categories of care, offering excellent facilities throughout. The full range of charges were not detailed in the service’s Statement of Purpose or Service User Guide’ documents as routine. The reader may wish to contact the service to obtain more detailed and up to date information about fees. Woodthorne DS0000033323.V367806.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 the people who use this service experience good quality outcomes. We conducted this unannounced inspection with the senior carer on duty, the Registered Manager having a prior appointment on the day. Our inspection of the building allowed us free access to all areas and open discussion with people who use the service, relatives and staff. There were 20 people in residence on the day of our inspection. We looked at how care is being arranged and supported for a range of people with health care needs. To do this we looked at (case tracked) three residents’ files from referral to the present time, and three staff files were examined. We also looked at other information such as complaints, incidents, events and other professional reports. We took the opportunity to speak with a number of residents, relatives and members of staff, who took an active role in the inspection process, and contributed to the subsequent report. We acknowledged receipt of the Annual Quality Assurance Assessment (AQAA), and survey forms returned by residents. We inspected a sample review of administrative procedures, practices and records, confirming consistent good practice and effective management. There followed a report feedback, in which we offered an evaluation of the inspection, indicating those recommendations resulting from the inspection. What the service does well: We found that Woodthorne offers a genuine commitment to care with a competent, yet open and personable approach, which reflects the homeliness of a confident relationship between carer and service user: “I have been very well looked after here, and I am aware of other homes and the quality of care is as good as it gets. My daughter is in your profession and she agrees with me”, “I like it here, its lovely, all the staff are very, very nice, and my key worker helps me all the time”. From examination of care records we established that there was an effective assessment, detailed care planning and review of individual needs, which are meaningful and robust, in formulating a good standard of care. When we Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 6 discussed the quality of care with residents and visitors, it was made clear that they appreciated this highly personable attitude and approach to care. The housekeeping, administrative and support services have all contribute to the team approach, and are recognised by the management for their efforts. We considered that the overall management style demonstrated a solid approach in maintaining an environment conducive to the care of the elderly. There is a regular appraisal and review process of facilities and services, to maintain that environment by the senior care management and Providers. What has improved since the last inspection? What they could do better: We considered that more variety in indoor activities would be beneficial, especially for residents with dementia and other cognitive impairments. Maintaining a consistent standard of décor and servicing is an area requiring more attention to complement the good standards of care observed. Consideration be given to providing sufficient hours of housekeeping services seven day a week to maintain a high standard of cleanliness. The achievements have been recognised, attention to areas of recommended detail will significantly enhance the provision of an honest, solid and homely service. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 7 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. Woodthorne DS0000033323.V367806.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 Woodthorne DS0000033323.V367806.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): 1,3,4, and 6. The quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The needs of prospective people are appropriately assessed before they are offered a place. They and their relatives can be confident that the service will be able to meet their needs. EVIDENCE: We examined the service’s revised Statement of Purpose and Service User Guide, and found them to provide an informative description of Woodthorne’s aims, objectives, and the way it operated. We acknowledged that the documents were presented to all enquirers, and a copy placed in each bedroom for people to read. We advised that the Service User Guide be produced in an Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 10 audio version to compliment the large print version already available. We also asked that fees presented to private applicants are to be included in the Guide. Our examination of three people’s care records and plans clearly demonstrated the extensive efforts to see through the pre-admission and admission assessments. We identified that the Care Manager or her deputy, at the point of reference, conducts the pre-admission assessment. We found each record showed the attention to individuality, with the assessment formulating a care support plan, based on individual needs, with aims and interventions. This assessment is produced with the involvement of residents and family, allowing them to influence the direction of care. The plan of care, which includes a profile with physical, mental and social assessments, stimulating a daily living plan. Comments received showed to us a confidence that residents and their families had in the service: “I like it here, its lovely, all the staff are very, very nice, and my key worker helps me all the time”, “I was made welcome and felt involved at all times” and “You have dealt with any concerns regarding R’s health promptly and tactfully, bearing in mind that he hates going to the doctor”. We acknowledged that any special needs of the individual were discussed fully and documented, ensuring their individual needs would be met. From discussions it was evident that prospective residents and their relatives are able to visit and assess the quality, facilities and suitability of the Home at any reasonable time, to meet with staff and management. No intermediate care took place in the home. Woodthorne DS0000033323.V367806.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): 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. A wide range of needs are addressed through the care planning process, meeting clear principles of respect, dignity and privacy towards people who use the service. Medicine administration systems are safe and secure. EVIDENCE: There was evidence to show us that a full review of the care process has produced a good standard of meeting care needs. We found that the profile of the resident’s social, physical and psychological status offered an individual plan of care, based upon dependency assessment and activities of daily living, Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 12 regularly and frequently reviewed. Three individuals’ care files were case tracked. Each demonstrated essential information on the individual, their life style and needs, events and contacts, procedures and actions monitored on a daily basis and reviewed monthly. Effective risk assessments had been completed in areas such as manual handling, falls, nutrition, tissue viability, and continence. This enables staff to identify risk areas and put systems in place to reduce risks. Our discussions with staff who were present confirmed an understanding of need, which is complemented with a system of named key-worker care staff. Case tracking confirmed to us that specialist support and advice are sought as needed, with each resident having access to a local Doctor, Dentist, Optician, and Chiropodist. They were seen to have access to appropriate medical health services, as required. We examined the care of a resident following a fall and minor head injury. All necessary actions had been dealt with satisfactorily, although it was advised that a period of recorded monitoring be established for all such cases in future. Carers were seen to interact with people who use the service with purpose and compassion. Several relatives were visiting and were asked for their comments on the quality of the service and care given. There was a clear appreciation of the openness and opportunity to contribute. All comments were complimentary of standards, facilities and staff: “I would like to say that I always find the members of the care staff and the managers very friendly and approachable”, “Satisfactory, we are very satisfied with mum’s care and know we only have to ask if we need to know anything”, “Family and friends are always made welcome”. We found the administration of medicines generally adhered to procedures to maximise protection to people who use the service. Our examination of the record of administration of medicines showed consistency, with no omissions observed. Staff training has been undertaken by Boots, and continues to be pursued actively by the care management team, especially for night staff. We acknowledged the discontinuation of the ‘Homely Remedy’ process. Controlled Drug management was reviewed and identified that a metal cupboard, Rag bolted to the wall would be required. It was acknowledged that that recommendation was acted upon immediately, with the pharmacy giving an undertaking to implement within the week. A controlled drug register was examined and we found to be up to date, although attention to the record of names and index would enhance safety. It was also advised that all medicine keys be kept together by the person-in-charge. It is stated in the service’s Statement of Purpose and the AQAA, that independence, privacy and dignity are encouraged, with the full involvement of Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 13 family in all matters concerning the well being of residents. This was confirmed, and that relatives and residents meetings had been held on a three monthly basis. In our discussions with residents and staff we confirmed that relatives have freedom of visiting, which emphasised the importance of maintaining social contact. We looked at bedrooms presented to facilitate privacy for the individual, which included medical examinations and personal care procedures being performed in private. Consideration is being given to facilitate a suitable bedroom door lock for dementia care situations, to enable selective periods of privacy, without prejudicing safety, to complement available lockable facilities. Our discussions with people confirmed that individual spiritual persuasions and individual diversity was seen to be respected. There are regular Church of England services held, and a Roman Catholic priest attends on request. Relatives are welcome to stay as long as they liked in times of stress, including overnight stay. We were impressed with the confidence and closeness within the Home of staff, residents and visitors, and the mutual respect that prevailed. Woodthorne DS0000033323.V367806.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): 12,13,14 and 15 The quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People’s rights to live a meaningful life are important to the home’s aims and objectives, and are offered opportunities to exercise choice and control over their lives. People are offered a healthy, well balanced diet, with choices for every meal. EVIDENCE: We found the daily routine to be flexible and non-institutionalised, offering choices for meal times, personal and social activities. Our discussions with residents and staff clearly identified a relaxed and informal atmosphere in which the people’s needs were respected, with the security that there are familiar events to the day they could relate to. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 15 Residents’ life histories are discussed and used as a basis for individualised social care offering choice and support. The Home boasts to celebrate people’s special days and occasions. We were informed that the Home is planning extended activities to add to those already in place included bingo, exercises, games, foot care and hairdressing sessions with occasional trips to the locality. During the course of the inspection we saw staff interact with residents in a positive and polite manner. We recognise the service’s principle that activities are a key element in the socialisation approach to care, with visitors encouraged to be involved in a partnership style with care staff. “I think a few more social activities could be provided, and some entertainment now and again” was one comment received by us. It is stated in the Statement of Purpose that personal choice and relative selfdetermination are respected in policy and action. Throughout the inspection we found this to be true. Those individual’s rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. Our inspection of the Home demonstrated a degree of expressed individuality in most of the bedrooms inspected. Personal identifiers on bedroom doors need to be established to improve familiarisation throughout the home. We found that the standards of catering offered an excellent service, to which residents spoken to were highly complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and suitable choice. We observed a very pleasant lunch served during inspection, with choices available of roast pork or fish fingers, served in a dining room adjacent to the lounge area. People interviewed confirmed that that the quantity and quality food provided was good. “I’ve always enjoyed my meals here”, “The cook is fantastic and meals are very good”, were two comments of many made by residents. Three meals were provided daily, with hot and cold beverages and snacks available throughout the day. We were informed that care staff sometimes takes up catering duties in the absence of the cooks. A birthday list was prominently placed in the kitchen. We confirmed that the cook knew each resident, and some of the relatives. We discussed diversity with the cook, who indicated an awareness in meeting individual needs; there were no special needs at the time. Individual preferences were recorded in assessment and conveyed to the catering staff, who met with, and discussed their requirements. Diabetic diets were seen to be catered for; “ Wouldn’t be anywhere else, for a residential house they are very capable in handling my diabetes”. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 16 We saw that staff offered discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of residents. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 17 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. The service has a meaningful complaints policy. People are given opportunities to freely express any concerns and these are quickly responded to. People are protected from abuse and their human rights are promoted. EVIDENCE: We found that peoples’ legal rights are protected by the systems in place in the service to safeguard them, including their contract, the continual assessment of care planning and policies in place, for example, the complaints procedure, which we examined. There were a few minor concerns, which we feel would be better dealt with through a ‘record of concerns, complaints and safeguarding’, to record peoples’, and their families’ concerns in a meaningful and effective manner. From our talks with people who use the service, and staff, it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. All people had received information on the procedure to complain, including reference to us. This process was evidenced through the Service User Guide, on examination and case tracking and discussion. We Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 18 identified that there had been no complaints or allegations made to us directly since the last inspection. “You have dealt with any concerns regarding R’s health promptly and tactfully”, “I feel I could raise any concerns I have regarding my father and staff.” Our discussion with the care management confirmed that there is satisfactory evidence of a protocol and response, to anyone reporting any form of abuse, to ensure effective handling of such an incident. The policy and procedure for handling issues of abuse was examined, and found to be appropriate. We examined three staff records to confirm that staff were suitably checked through Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (POVA) disclosure. We found staff received training on abuse at induction, this includes the right to ‘whistle blowing’ consistent with the Public Disclosure Act 1998. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 19 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): 19,24,25 and 26 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Woodthorne provides a safe, well-maintained, clean and comfortable environment for the people who use the service. The state of décor in some places is need of renewal. EVIDENCE: Our inspection of the home verified that the premises were generally fit for purpose, clean warm and tidy, and being satisfactorily maintained. However the state of décor has not been maintained accordingly. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 20 External car parking and grounds were found to be satisfactory and well maintained. There is an attractive garden with a patio area; overlooked from some of the rooms, the lounge and the conservatory. The state of repair and maintenance is generally very good, offering a comfortable, homely yet secure environment. We were informed that a handyperson was to be appointed shortly. We were informed that on admission the Care Manager assesses each individual’s needs for equipment and necessary adaptations, we found this to be correct, and saw those facilities available throughout the Home, with suitable fittings of hand and grab rails, in adequate, well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the Home. We found communal spaces furnished in a traditional style, yet presented a homely atmosphere, offering social as well as private reflection, as the mood takes. Efforts had been made to provide a homely atmosphere and the décor in most areas of home was found to be of an adequate standard. Recent decoration of bedrooms, new carpets and upgrades to bathrooms were very satisfactory, although there remains a significant number of issues to be addressed, some with a barely adequate standard of decor. The lounge spaces allow activities to be presented in very pleasant areas of the home, with furniture and fittings of good quality. The dining area is well furnished, and presented to provide a conducive environment to enjoy a good meal. Staff supervision is available throughout the day. Each of the bedrooms were seen to have been personalised with people’s possessions and some furniture brought in with them. We tested the call alarm system with a satisfactory result. All personal electrical equipment were seen to be PAT tested. People we spoke to during the course of the Inspection expressed their general approval of their accommodation standards, which was complemented with the large number of personal items brought in to enhance the homeliness of their rooms. Some wardrobes were found to be insecure, requiring fixture to abutted wall. “Our family is completely satisfied”, “It would be nice to have a decoration of my room, but altogether it’s very nice and homely”, and “It’s not my home but it will do nicely”. The home presented to us a generally clean and pleasant, odour-free atmosphere, much to the credit of staff. To complement the presentation there were numerous floral and decorative displays. We noted the need to cover housekeeping duties on a seven-day basis, to maintain standards. We advised that store areas and the sluice be kept secure when not in use. Toilets and bathrooms were located in close proximity to bedrooms and communal areas. Each bathroom had a bath thermometer, and hot water checked was within safe limits. It was noticed that a damaged toilet had rendered a bathroom inoperable, awaiting repair. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 21 Kitchen presentation showed satisfactory standards of cleanliness, and evidence of sound food hygiene practices. A scheduled cleaning rota was advised to demonstrate the standard seen by us. We also advised the cook to ensure a protective apron/coat be made available. We found the laundry was well organised and equipped to a good standard, regulations were available, and would be enhanced with posters clearly displaying, and relevant to, solutions in use. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 22 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels ensure that suitably trained staff are provided to meet the needs of people who use the service. Recruitment processes are consistent and robust, protecting the people who use the service from harm and abuse. EVIDENCE: There were 20 people using the service in the home on the day of the inspection. We examined three weeks of off-duty rotas, in which the daily care staffing showed adequate balance between skills, qualifications and numbers to provide a foundation for a good standard of care. We determined that the catering and domestic hours were found to be barely adequate, each reliant on care staff to support in times of need. The 27 hours of housekeeping is considered to need boosting to provide a service for seven days a week. We examined three staff files, each providing satisfactory evidence that the process of appointing new staff were well organised, consistent and contributed in safeguarded the interests of residents. We found that the Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 23 Providers and care management have established a thorough procedure for interview, selection and appointment of staff. This involves a standard application form to assess and profile, two references taken and Criminal Record Bureau (CRB, enhanced) checks gathered before a contract is offered to successful candidates. The thoroughness of staff selection has a significant effect upon the provision of cares to ensure protection of people. We interviewed three staff on duty, each spoke well of the training and supervision offered to them, and of the good working conditions that prevail. Our discussions with staff also confirmed their commitment to providing a quality service, and their awareness of the principles of good practice and Code of conduct. There were no problematic issues raised by the staff. Comments we received included: “I would like to say that I always find the members of the care staff and the managers very friendly and approachable”, “Everyone is very helpful and do all in their power to see that Im right”, although one stated: “The staff are outstanding, very kind and will do anything for you”. There is a satisfactory staff induction programme, which we found initiated a formal in-house training schedule. National Vocational Qualification (NVQ) programmes continue with a commitment from the managers. We accept the commitment to care education as sustained and enhanced. Staff have received training on mandatory and specific issues, including fire marshalling, dementia care, conflict management and medication training. The supervision programme is firmly established, which involved establishing a shared aspect of responsibility between staff and supervisor. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 24 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 The quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care team promote the health, safety and welfare of people using the service, and working practices are safe. People who use the service can be assured that the home is run in their interests. The ethos of the service is based on openness and respect. EVIDENCE: Although not present at the time of this unannounced inspection we have found that the Care Manager Ms Satwant Chahal has demonstrated effectiveness in establishing a solid management foundation implemented, to Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 25 achieve a good standard of set aims and objectives. She has been actively engaged in quality reviews and audits, following our last inspection, meeting compliance to requirements and addressing recommendations we made, especially in the improvements made in keeping families and residents informed, and involved. She has achieved her NVQ Level 4 and Registered Managers Award qualifications. We were impressed by the openness, professional and pleasing confidence in the observed interactions of staff, relatives and residents. The relationships were seen to be of mutual trust and respect. We saw records of resident and relative meetings that are a regular feature of quality assurance. Comments from those attending included: ““ Wouldn’t be anywhere else, for a residential house they are very capable in handling my diabetes. I’m a forceful sort and will say my peace, but have no problems or complaints – very pleased with the home” and “Everyone is very helpful and do all in their power to see that Im right”. One comment received: “I think a few more social activities could be provided, and some entertainment now and again”. Through the inspection process we found appropriate risk assessments in place for residents, through care planning and recording, staff selection and the general environment, these are up to date and accurate. A fire risk audit has been recently completed, which will pave the way for a full risk analysis of the Home. Health and safety notices can be seen throughout the Home. An examination of administrative, monitoring, planning and care records showed to us an organised and professional attitude to effective record keeping. They were found to be generally well maintained in ensuring that the people’s rights and best interests are safeguarded. The Manager offered evidence of safe working practices including: - Dementia awareness, first aid, abuse awareness, and disposal of medicines. The accident book was seen and found to be in order for staff and residents, with a three monthly analysis of trends and frequency. A first aid box was examined which needs updating to be effective. We were informed that the financial arrangements are controlled by the administrator in respect of pocket money, comfort fund and petty cash management. We found this to be so, with the systems uncomplicated, and easy to understand and effective. The administration and management of the Home has achieved a great deal over the past year in setting a solid foundation to practice care, and sensitive to the needs of people who use it. Attention to a substantial number of Requirements and recommendations made by CSCI, have been acknowledged. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 26 Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 27 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 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 2 X X X X 3 2 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 3 X 3 X 3 X X 3 Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP22 Good Practice Recommendations Identify the allocated room identifier in service users’ contract to complete a clear understanding of residency. Establish the practice of implementing a recorded monitoring process for residents following medical referrals for accidents. Ensure a robust medication system to include: Fixing a secure, Rag bolted, controlled drug (CDA) cabinet, and clear indexing of CDA register. Greater variety in activities would be beneficial, especially for residents with dementia and other cognitive impairments. A concerns, complaints and allegations book be established. DS0000033323.V367806.R01.S.doc Version 5.2 Page 29 OP7 3 OP9 4 OP12.3 5 OP16 Woodthorne 6 7 OP19 OP24 It is recommended that the system should be put in place to ensure that the essential repairs such as those identified in this report are dealt with promptly. A re-furbishment plan be drawn up to address improvements for 2008/09, to offer advance information on the level of development of the service, and enhancement of décor throughout. Consideration be given to providing five hours of housekeeping services seven day a week to maintain a high standard of cleanliness. Bedroom wardrobes are to be secured to abutting walls to ensure resident’s safety. As a course of good practice COSHH laminate posters should be located in areas where chemicals are stored 8 OP27.7 9 10 11 11 OP38.4 OP38 OP38 To limit access to the kitchen area to authorised staff only in maintaining essential hygiene standards. Ensure cleaning record in the kitchen is kept up to date, to evidence the observed good standard of cleanliness in the kitchen areas. Woodthorne DS0000033323.V367806.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. 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