Inspection on 10/12/07 for Woodwell House

This is the latest available inspection report for this service, carried out on 10th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodwell House 19/12/05

Woodwell House 25/08/05

Woodwell House 18/12/04

Woodwell House 24/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Woodwell House 227-229 Nibley Road Shirehampton Bristol BS11 9EQ Lead Inspector David Smith Key Unannounced Inspection 10th & 12th December 2007 10:30 Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 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 Woodwell House DS0000026588.V348867.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 Adults 18-65. 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. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodwell House Address 227-229 Nibley Road Shirehampton Bristol BS11 9EQ 0117 9381942 0117 9382551 admin@avon-autistic.demon.co.uk 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) Avon Autistic Foundation Ms Ann Coleman Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 12 persons aged 18 - 64 years Date of last inspection 16th March 2007 Brief Description of the Service: Woodwell House is owned and operated by the Avon Autistic Foundation and provides accommodation and personal care for up to twelve people aged between eighteen and sixty four years. Avon Autistic Foundation specialises in supporting people who have a diagnosis of autism or Aspergers Syndrome. The Foundation also operates a day centre providing a range of social and educational activities. Woodwell House is a purpose built home and consists of two properties linked by a corridor. The property is situated in a quiet residential area close to local amenities and bus routes. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home as part of a Key Inspection of this service. The review of evidence and pre-inspection planning involved reviewing the report of the last Key Inspection carried out in March 2007 and the service history, which details all contact with the home including notifications of significant events which they have reported to us. We (the CSCI) provided the home with their Annual Quality Assurance Assessment (known as an AQAA, pronounced as ‘aqua’) and a range of survey forms for service users, their relatives, carers, advocates and health professionals, prior to my visit. The AQAA was completed and returned together with one survey. I gathered additional information during my visit through informal discussions with service users and Support Workers. Interaction and communication between staff and service users was also observed. Care plans and associated records were examined together with Risk Assessments, complaints procedures, medication administration, staff personnel and training records and health and safety records. I was also provided with a tour of all communal areas of the home and some of the service user’s own rooms. This inspection was also supported by an ‘Expert By Experience’ who, because of their shared experience of using services, helped us to get a picture of what it is like to live in this home. They visited the home during the late afternoon and early evening, spent time with individuals who live at Woodwell House and spoke with three service users and two members of staff. What the service does well: The home provides a high standard of care for individuals who have complex needs, delivered through a person centred approach. Service users have a varied life at the home, and are able to choose from a range of activities offered at the day centre located nearby. Our ‘Expert By Experience’ said service users had lots of choices and are involved in the running of the home. The home actively seeks support from other professionals to help improve the quality of the service it provides to each person. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 6 Staff members receive appropriate support, guidance and training to ensure a high standard of service is provided to each person who lives in the home. The home is spacious, and each individual has a large airy bedroom. The home is well maintained, and the furniture and fittings are of a good standard. Our ‘Expert By Experience’ said the home has a very relaxed atmosphere, is warm, spacious and is a very nice place for people to live. The home is well run. The ethos of the service is clear, well communicated and remains focused on positive outcomes for each service user. What has improved since the last inspection? What they could do better: The home should consider improving Risk Assessments in relation to individuals who may require restrictive physical interventions as part of their behaviour support plan. This would better promote the welfare and safety of each service user and the staff team. Each member of staff should be provided with refresher training to enable them to respond in a planned and safe manner to service users who are Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 7 displaying behaviours which may be seen as challenging the service being provided. 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. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have access to detailed information in order to make informed choices about where to live. EVIDENCE: The home has a Statement of Purpose and Service Users’ Guide, which contain comprehensive information about the home and service it is able to provide. The Service Users’ guide has been developed with the use of pictorial information which helps individuals to understand its content. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that the service provided to each individual takes into account their personal preferences, supported by both written information in care plans and risk assessments which are subject to ongoing review. Service users are consulted on, and given opportunities to participate in, all aspects of life in the home. EVIDENCE: Two service user support plans were examined in detail and these provided comprehensive information on the areas of support each person required. Each plan had been written in an individual way and covered key areas of support people required, such as domestic tasks, health care, communication and work towards their goals. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 11 Regular formal review meetings are held, which include service users, their families, staff members, Social Workers and their Keyworker (one member of the staff team who works closely with one service user). Each service user is supported to prepare for, plan and attend their review meeting if they wish to do so. These meetings are clearly recorded and the outcomes used to update individual support plans. In addition to these formal reviews, the home has now developed a very effective system of reviewing each care plan in-house, which is good practice. Each Keyworker writes an ‘end of month report’ for one service user, which details each significant event that month and gives an overview of their health, mood and progress towards their goals. The home also uses a ‘Re-Assessment Form’ in each section of service users’ care plans. This is completed by either the Manager or her Deputy to ensure each care plan remains up to date and that any changes are noted and communicated to each member of the staff team. The records I examined show that care plans are now formally reviewed at least every two or three months, or earlier if an individual’s needs change. In addition to care planning documents, each individual also has an ‘Individual Personal Plan’, known as an ‘IPP’. This clearly describes the goals that have been identified and agreed by each service user. The support required to enable each person to realise their goals and the progress of working towards them are both regularly reviewed. Interactions between staff and service users were observed during the afternoon of my visit. These demonstrated the staff had a good knowledge of the support needs of service users and how to communicate effectively. Discussion between the Manager, staff members and myself also confirmed this. I did speak with service users, however due to their communication difficulties and them not knowing me, it was difficult for me to gain information regarding their service directly from them. However, one individual does use sign language and did sign ‘good’ and ‘happy’ to me when I signed to ask if he was happy living in the home. Another three individuals were interacting with staff whilst the evening meal was being prepared and they appeared happy and relaxed in the company of staff and were able to communicate with them. It is evident that each person has different ways of making choices and these are explained within each support plan. The home uses different methods to support this such as using pictures or photographs to offer choices. Some service users use pictorial daily planners, some use sign language such as ‘Makaton’ and other are being supported with the use of ‘PECS’ which involves exchanging pictures to communicate and make choices. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 12 There are now regular meetings with each service user, which are called ‘Suggestions or Concerns Meetings’. These cover a wide range of topics and are designed to help each person express their views, likes, dislikes and involve them in their care planning as much as possible. This is a positive development. Our ‘Expert By Experience’ said that service users told them they are able to make choices, such as how to spend their leisure time, what sessions they wish to attend during the day, what time they go to bed and what they wish to watch on television. If they have made plans, but then change their mind, this is respected. Care and support is provided within a risk assessment framework. Each of the person centred risk assessments I examined were detailed and have been regularly reviewed. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each individual has opportunities and appropriate support to develop, access leisure and educational facilities both locally and in the wider community including day trips and visits to family and friends. Each person’s rights and responsibilities are recognised in their daily lives. A healthy and balanced diet for each individual is promoted. EVIDENCE: Service users are able to attend a day centre attached to another home within the organisation, which offers a wide variety of sessions and courses. Individuals are also supported to use facilities in the wider community. The records I examined showed that service users are going out for day trips, picnics, walks, to aerobics sessions, going swimming and attending other social Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 14 events such as a recent firework and karaoke party. On the day I visited all of the individuals who live in the home were out attending planned activities for most of the day, returning to the home at approximately 4.00pm. Our ‘Expert By Experience’ said that service users and staff told them that individuals are supported to play various sports, go swimming, ten pin bowling, shopping at Cribbs Causeway, use the local library, go to the cinema, attend church and help with cooking. They also go out for day trips to places such as Chepstow Castle, Chew Valley Lake, Bath and Berkley Castle. One individual said they “went to see (the latest) Harry Potter Film” and another said “I like playing football in the garden”. They were also told that the Christmas tree will arrive next week, which everyone helps to decorate, and staff and service users have organised a Christmas Meal and Disco. They felt it was good that service users and staff went out together to celebrate Christmas. Each service user has any goals they are currently working towards noted in their care plan. These goals vary depending on the skills and abilities of each person. The records I examined show that individuals are being supported to improve their communication skills, use some equipment in their home independently and improve daily living skills. There is a clear process of reviewing the progress each person is making in working towards their goals. The home reviews progress each month and the outcome of the review is added to each person’s care plan. This is supported by the day centre, who also write their own monthly report and provide a copy to the home. I did note that service users are making progress and if they are not, support is adapted or changed to better support them. I also noted in the review documents I examined that parents had said they felt their relatives are making good progress and they are happy with the service being provided. Service users are supported to maintain regular contact with their family and friends and visitors to the home are welcomed. Staff support service users to write regularly to their parents, some families visit the home often and some individuals stay with their families, at weekends or Christmas for example. Observation during my visit and discussion with staff shows that each person who lives in the home is treated with respect and dignity. Each person is seen as an individual and treated as such. The menus show that each individual is offered a choice of healthy and nutritious food. Service users continue to be encouraged to choose the food they would like to be included on the menu and their general likes, dislikes or dietary needs are known by the staff. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 15 Our ‘Expert By Experience’ said that service users do require support in the kitchen, but are able to have food and drinks when they wish. They said they do help with the cooking, such as preparing vegetables, load and unload the dishwasher and lay the tables before meals are served. The home has two dining rooms, where service users eat their meals. These are both clean and well furnished. They both look out over the rear garden and provide a pleasant environment for people to eat in. The kitchens are clean, tidy and well organised. Staff are provided with Food Hygiene training and are also now completing the ‘Safer Foods, Better Business’ document provided by the Food Standards Agency. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in their preferred manner and their personal and healthcare support needs are well met. The policy and procedures relating to administration of medication ensures service users’ welfare and safety. EVIDENCE: The care documentation in place for service users provides clear guidance for staff on how they should support those living at the home with their personal care. The care plans I examined show that service users are registered with a local GP, dentist, optician and chiropodist. Other specialist services are accessed when an identified need arises. Care records show the home is supported by Psychologists and other relevant health care professionals. Contact with each professional is recorded and forms part of each persons care plan. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 17 There is a core of experienced staff who have a good knowledge of service users’ healthcare needs. Any changes, which may cause staff concern, are noted and acted upon. It remains evident that the management and staff spoken with are sensitive to the personal, healthcare and emotional needs of those living in the home. The home’s GP, who responded by survey said the home works in partnership with them, their advice is incorporated into care plans and staff demonstrate a clear understanding of the care needs of each service user. The home uses a Monitored Dosage System of medicine administration. This system is now very well managed. Medication is stored securely in locked cabinets on the ground floor of the home. The medication records I examined contained profiles of each service user, a recent photograph, details of their medication, times of administration and manufactures notes on each of the prescribed medications administered within the home. Each service user’s medication record was correctly completed, signed by staff with no gaps evident in the records. Any medication which is given ‘as and when required’ (known as ‘PRN’) is clearly noted and staff told me this medication is never given unless it is authorised by the ‘on-call’ Manager. The home has developed a robust procedure for recoding all medication entering or leaving the home and checking stock levels and expiry dates. These systems were explained to me in detail be the Trainee Assistant Manager, who oversees medication administration in the home. Each record I was shown was up to date and the new systems in place in the home are easy to use and to follow. Each member of staff who dispenses medication is provided with appropriate training, together with an in-house assessment. There are regular medication reviews carried out by a Consultant Psychiatrist. The frequency depends on the individual concerned and these varied from sixmonthly reviews to as frequently as every two months. The home’s GP said in their survey that they felt medication is appropriately managed in the home. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. Clear policies and procedures are in place in order to protect service users from the likelihood of abuse, neglect and self-harm. EVIDENCE: The home has a formal Complaints Policy, an Adult Protection Policy and a Whistle Blowing Policy, which staff can use in confidence to raise any issue or concern they have regarding the service. There have been no complaints or concerns received by the home since the last inspection visit. Staff members now spend time every month with service users in their ‘Suggestions or Concerns Meetings’, referred to earlier in this report. These meetings do provide an opportunity for each individual to either say or show if they are unhappy about any area of the service provided by the home. A clear record of each meeting is kept as part of each person’s care plan and all issues are acted upon. Due to the communication difficulties experienced by the people who live at Woodwell House, this appears to be an appropriate method to use, rather than Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 19 relying on service users using the formal complaints procedure, which they are very unlikely to do. All staff are now provided with training in relation to the Protection of Vulnerable Adults and are subject to ‘enhanced’ Criminal Record Bureau disclosures (known as ‘CRB’s) before they start work in the home. The home has clear guidelines in place for supporting service users who are distressed or presenting behaviours which may be perceived as challenging the service provided. Each care plan has details of known trigger points and the appropriate defusing techniques. Staff receive training in understanding and responding to these behaviours, using in-house training materials. The Manager told me this training is more focused on theory rather than more practical or physical responses. Some individuals may require physical interventions, including staff using block or breakaway techniques, however these do not form part of the general in-house training programme. Some staff have previously had physical intervention training (provided by an external trainer), however this should be provided to all staff, including refresher training for those who may have had this in the past. Service users are generally supported within a risk assessment framework; however, there are no clear risk assessments currently in place relating to the use of physical interventions with those individuals who may require this level of support. These should be developed as soon as possible and I did share the Department of Health Guidance on Restrictive Physical Interventions, which the home may wish to use to support these developments. The home maintains clear records of all accidents and incidents and notifies us of any significant event which occurs. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodwell House provides a very homely, comfortable and safe environment for service users to live in. EVIDENCE: Woodwell House is purpose built and consists of two properties linked by a corridor. The home is situated in a quiet residential area close to local amenities and bus routes. There is a large car parking area at the front of the house and mature, well kept gardens at the side and rear of the home. The communal facilities in each house include a lounge, dining room, kitchen, visitor’s room and communal toilets and bathrooms. Each service user has their own room, with en-suite facilities. I did view all of the communal areas, along with some of the service user’s rooms. All areas of the home were very clean and tidy and furnishings and Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 21 fittings are of a good quality. The house is tastefully decorated and contract cleaners, who clean the home each week, were working in the home on the day of my visit. Our ‘Expert By Experience’ said they felt the home had a very relaxed atmosphere, was warm and felt spacious. They said service users appeared relaxed at home and the staff are friendly. Service users are encouraged to help keep their home clean and tidy. Each person’s bedroom has been decorated and furnished to make it personal to them. There were lots or personal effects, pictures and photographs which added to this. The large rear garden has been designed over several levels and includes a range of garden furniture and a fishpond. Staff told me one individual who lives in the home had chosen to buy a greenhouse, which is in the garden. Our ‘Expert By Experience’ said this individual plants seeds, bulbs and vegetables, with the support of staff. They also help with some digging and have made hanging baskets for the garden with plants they have grown from seeds and help to water these in the summer. All of the staff members I spoke with said they worked hard to create a homely look and atmosphere at Woodwell House, ensure the house is well maintained and provides a safe and secure home for each individual to live in. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The clarity of staff roles and responsibilities along with staff training and supervision helps to provide a consistent approach to the support of staff and service users. The home’s recruitment policy promotes both service users’ rights and their safety. EVIDENCE: There remains a core of well-established staff with varying abilities who are skilled and experienced to meet the needs of those living in the home. Staff members I spoke with said that the staff team is open, honest and supportive. They felt well supported by the management team and were able to discuss issues in an open and honest way. Staff were observed interacting well with service users and those spoken with demonstrated a good understanding of the support needs of each person who lives in the home. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 23 The staffing arrangements are more complex than other similar homes, as staff members do accompany service users and support them during their daytime activities, as well as supporting them at Woodwell House. The home’s rota has now been re-designed to show which staff are working within the home and the precise times of their shifts. The home does have vacancies for two full time Support Workers, however these hours are currently being covered by the home’s Bank Staff or by regular agency staff. Staff meetings have now resumed, with the last meeting held on 20/11/07. Clear records are kept of each meeting, together with the names of staff who attend. There are other, more informal meetings or discussions with staff, which are also recorded. Our ‘Expert By Experience’ said the staff working in the home “were friendly” and when they asked two service users if they liked the staff who supported them, they signed that they did. I examined the personnel records of some newer staff members. These contained a photograph of each staff member, copies of their Application Form, at least two satisfactory references, documents confirming identity and eligibility to work in the UK, contracts of employment and a record of their induction to working in the home. (The details of Enhanced Disclosures from the Criminal Records Bureau are discussed earlier within this report). Staff are provided with a variety of training opportunities, most of which are provided in-house and some by external training providers. The home has worked hard to ensure staff are provided with all core training, although this has been a challenge at times due to external training sessions being full. The records I examined showed that staff have had training in First Aid, Adult Protection, Food Hygiene, Challenging Behaviour, Medication Administration and Fire Safety. The organisation has developed their own comprehensive induction and training package for staff, with a particular focus on the Autistic Spectrum and Aspergers’ Syndrome. This is known as ‘Avon Autistic Foundation Induction and Theory’ and has three separate stages. Each member of staff works through each stage and then sits a written test under ‘exam conditions’. This test paper is then marked and each member of staff must complete each stage before moving on to the next, higher stage. Staff are encouraged to work towards a National Vocational Qualification (known as an ‘NVQ’). One staff member I spoke with is currently working towards NVQ Level 3 and this is being supported by an Assessor from a local college. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 24 Each member of staff is provided with regular formal supervision, with the frequency being improved since our last visit. Clear records of each meeting are kept which both parties sign. Staff spoken with said they continue to find supervision helpful and supportive. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well-run and service users benefit from the ethos, leadership and management approach of the home. Service users views are sought in relation to the monitoring and review of the service provided by the home. Each person’s rights and best interests are promoted by the home’s record keeping and the organisations’ policies and procedures. The health, safety and welfare of people living in the home is promoted and protected. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 26 EVIDENCE: The Registered Manager, Mrs Ann Coleman, and Mr John Coleman, the Registered Provider were both present during my visit and supported the inspection process. Through my discussions with Mr. and Mrs. Coleman it is clear the management approach remains open and positive, with a clear sense of direction and leadership. The ethos of the service is person centred with the views of service users being sought, as far as possible, as part of this process through their monthly meetings with staff members. These discussions also confirmed the commitment to the development and improvement the service, where this is possible. This includes the action taken to meet each of the requirements and recommendations from our last inspection report. The management structure and lines of accountability within the home are clear and straightforward. The Registered Manager is supported by a Deputy Manager and one other person currently training as a Deputy Manager. Out of hours management support is always available for staff, as the organisation operates an ‘on call’ system. There are efficient management systems and structures in place to ensure the home runs effectively. The quality of record keeping in the home is very good, with all records required during my visit easy to access and stored securely when not in use. Avon Autistic Foundation have comprehensive policies and procedures to support the home, which are designed to ensure it complies with the law and remains aware of good practice guidelines. Each member of staff is asked to read the home’s policies and sign to say they have done so. The registered provider makes regular visits to the home, and produces a report of his findings. A copy of each report is forwarded to us each month. There are recording systems in place to support Health and Safety within the home, which are being used consistently. Records examined included fridge and freezer temperature checks and tests on the temperature of high-risk foods. There are a number of general Risk Assessments in place to ensure the welfare of service users and staff. These have all been recently reviewed. Woodwell House DS0000026588.V348867.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 Adults 18-65 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 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 4 3 3 Woodwell House DS0000026588.V348867.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 YA23 YA23 Good Practice Recommendations Risk Assessments for service users who may require physical interventions should be improved to promote the welfare and safety of both service users and staff. Each member of staff should be provided with physical intervention training, or a refresher, to enable them to support service users in a planned and safe way. Woodwell House DS0000026588.V348867.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Woodwell House DS0000026588.V348867.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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