Inspection on 17/10/06 for 17 Woodrows Lane

This inspection was carried out on 17th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Woodrows Lane 17/09/09

17 Woodrows Lane 27/09/07

17 Woodrows Lane 01/11/05

17 Woodrows Lane 11/04/05

17 Woodrows Lane 05/10/04

17 Woodrows Lane 06/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 17 Woodrows Lane Bockings Elm Clacton On Sea Essex CO16 8DN Lead Inspector Pauline Dean Key Unannounced Inspection 17th October 2006 10:10 17 Woodrows Lane DS0000017723.V316291.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 17 Woodrows Lane DS0000017723.V316291.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 and 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. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 17 Woodrows Lane Address Bockings Elm Clacton On Sea Essex CO16 8DN 01255 433057 N\A 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) Mr Liyanage Lal Gunaratne Miss April Phillips Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (3) of places 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 6 persons) Three named persons, over the age of 65 years, who require care by reason of a learning disability, whose names were supplied to the Commission The total number of service users accommodated must not exceed 6 persons 1st November 2005 Date of last inspection Brief Description of the Service: 17 Woodrows Lane is a detached chalet bungalow offering care for six people with learning disabilities. The property is in keeping with the local community and is sited in a residential area. Accommodation is on the first and ground floors, with three single rooms on the first floor and one double and one single on the ground floor. Shower, bathing and toilet facilities are found on both floors. The ground floor single bedroom has an en-suite facility of a wash hand basin and toilet. Communal areas consist of a lounge, dining room and a small conservatory/lobby. There are gardens to the front, side and rear of the bungalow. There is a garage and a storage shed. The home is within walking distance of local shops, parks and schools. Public transport is close by and the home has their own transport. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, covering the key National Minimum Standards, took into consideration all recent records relating to the service, including information sent to the Commission by the Provider. A record of inspection was collated prior and during the inspection process. It also included a site visit to the home on 17/10/06, which lasted approximately 8 hours. At this visit, the inspector was able to speak with some service users as they went about the home, the registered manager – Miss April Phillips and care staff. A tour of premises was completed and there was observation of care practice and the sampling of records. Where possible, the site visits focussed on the experience of a sample of three service users, a process known as case tracking. Of the twenty-five National Minimum Standards inspected on this occasion, fourteen were met, nine nearly met and one nearly met which is highlighted as a recommendation. These include one repeat requirement from the last inspection. Overall there has been an improvement in the both the care practice and record keeping in the home. What the service does well: What has improved since the last inspection? Care planning and record keeping is now produced on the home’s computer. This has made the documents easier to read and greatly aided the process of updating and amending. Ongoing maintenance and decoration ensures that the care home is clean and tidy. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 6 Basic training courses are programmed in to ensure that staff have the knowledge they require to do their job. 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. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. (Adults 18-65) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. Documentation ensures that service users move into the home knowing that their needs will be met. EVIDENCE: There have been no new admissions since the last inspection in November 2005. The most recent admission was in August 2003 when documentation 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 9 was received from the service user’s previous care home and the placing authority. Detailed assessments were completed by the latter. Currently 17 Woodrows Lane has full occupancy. Miss Phillips highlighted her plans on the processes and practice the home would undertake for future admissions to the care home. In total three service users files were sampled and used as part of the case tracking exercises. All three had contracts in place, which detailed specifications as stated in the National Minimum Standards – Standard 5.2. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. (Adults 18-65) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. Care planning documents detailed health, personal and social care needs and records evidenced all aspects of care required. Service users are enabled to make decisions through risk assessments and risk management. EVIDENCE: 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 11 A plan of care had been developed for all three of the service users involved in this case tracking exercise. Either seventeen or eighteen objectives are considered as is applicable to each individual service user. These objectives covered all aspects of personal and social support and healthcare needs. Within these documents there was evidence of staff management strategies and intervention and the records clearly detailed who is responsible for what action. Outside agencies were also noted in this action. From consideration of the sampled files and discussion with the registered manager it was apparent that care plans are seen as ‘living’ documents, for examples of changes to care planning goals and needs were seen following reflection on daily records and findings. Service users are encouraged and enabled to make decisions about their lives. Whilst the inspector was not able to consider this individually with all of the service users, it was evident from care planning records and conversations with two service users that their individual choices are acknowledged and planned for in their care plans. This was particularly relevant with regard to selecting college courses and holiday planning. Risk assessments and risk management strategies were found in all three of the sampled care plans. These covered a variety of activities and were seen to be relevant to the individuals. The need to review these documents and consider re-formatting was discussed with Miss Phillips. for it was acknowledged that present formats needed revision to enable service users’ key workers to undertake this task. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 13 12, 13, 15, 16 and 27. (Adults 18-65) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. Staff support and assist service users to participate in educational, training and community activities, as they are able. Staff support service users to maintain family links & friendships. Service users rights are respected and responsibilities are recognised. EVIDENCE: It was evident from sampling three service users’ files that 17 Woodrows Lane encourages service users to attend college courses and take part in individual activities. Three service users attend classes at the Harwich Centre. Courses attended included a Work skills Course, Self-Advocacy, Words & Numbers, Work Awareness, Gardening, Independent Living Skills, Woodwork and Crafts, Cookery, Pottery and Communication. On returning from college, one service user spoke of enjoying their college course and they were pleased to be able to access these courses. Miss Phillips said that service users are encouraged to use local community facilities. Two or three of the service users regularly use the local library and visit local pubs for a meal and a drink. All service users now have a bus pass and this enables them to make the short bus journey into Clacton on sea. Service users are escorted on these trips. Miss Phillips said that recently the home had had to complete the electoral role and she anticipates that two of the service users will use their vote. Of the six service users, only three service users have maintained contact with their family. Miss Phillips said that this was the position as they had come to live at 17 Woodrows Lane. Three service users still maintain contact with their relatives. This was confirmed in the survey work conducted by Commission for Social Care Inspection (CSCI). Two comment cards were completed and returned to the Commission for Social Care Inspection (CSCI). Both spoke very positively regarding the care of their relative. Comments such as “I am delighted with 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 14 the care my brother receives at Woodrows. The staff are very friendly and approachable” and “Having seen the staff in operation at Woodrows Lane, I have complete confidence in their ability/efficiency and they are to be commended” were made. From observation and sampling care plans evidence was seen of staff respecting the rights and responsibilities of service users. Care plan records and risk assessments detailed whether service users are offered a key to their bedroom. During the site visit, service users were seen to go around the home as they wished, spending time in their room, in the lounge and out in the community at college. Two service users were out at college for the majority of the day, whilst another service user went shopping with a care worker. Another care worker chose to sit in the lounge watching a film. Miss Phillips said that three service users had enjoyed a holiday at a holiday centre in Great Yarmouth and a fourth had had a mini-break to see the illuminations at Blackpool. Miss Phillips said that the remaining two service users did not wish to go on holiday, preferring the occasional day out. 17 Woodrows Lane operates a four-week rotation menu. Choice is offered for all meals with records detailing the food eaten. The main meal of the day is normally in the evening, with two service users taking a packed lunch when they attend college. Food supplies are purchased from local supermarkets at least two or three times a week. Seasonal changes and preferences are considered in the menu planning. One service user has a low-fat menu plan and their meals are prepared alongside the main menu with efforts made to produce similar meals. Records were seen of the food eaten by each individual service user. During the site visit, the inspector saw the preparation of the evening meal and some service users were encouraged to assist with the preparation and the laying of the table. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. (Adults 18-65) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. The home’s arrangements for supporting the healthcare of service users were satisfactory, with the record keeping and medication administration well managed. EVIDENCE: 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 16 It was evident from observation and record keeping that service users were able to get up and go to bed as they wished. Privacy and dignity were considered when offering personal support, for this was offered in private as needed. To enable continued independence appropriate technical aids and equipment has been introduced for one service user. The inspector was told that an occupational therapy assessment has been completed new grab rails; a bath seat and handling belts have been introduced. The district nursing service had also been called in to consider pressure sore identification and prevention. Service users are support and assisted to attend healthcare visits. Records detailed visits to GPs etc. and any changes to care plans are made as required. Health Action Plans as introduced by the local health authority have been completed for service users. Miss Phillips said that these plans are used to record and note all healthcare appointments. Within the case tracking exercise records were seen of visits to health care professionals. Regular visits to both dental surgeries and the chiropodist were seen and consultants and specialists are accessed as needed. A response has been received by Commission for Social Care Inspection (CSCI) from a Community Nurse. They said that they had never ‘had any concerns about the standards of care’ at the home and the felt ‘that a good service is provided’. Medication administration, storage and record keeping was sampled and inspected for the three service users who were part of the case tracking. Overall, this was found to be in good order, apart from one shortfall. Medication had clearly been administered for a service user, but they had failed to record this on the Medication Administration Record (MAR) sheet. This was discussed and considered with the registered manager and the home was advised to review the knowledge and understanding of care staff administering medication and their training needs. Records were seen of medication entering the home and leaving the home. All medication is held in a secure storage cupboard in the home’s office. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. (Adults 18-65) Quality in this outcome is is adequate. This judgement has been made using available evidence including a visit to this service. Overall, service users were well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: 17 Woodrows Lane has a complaints procedure. This however requires review and revision for reference to Commission for Social Care Inspection (CSCI) is incorrect with regard to the role of the Commission. It should be noted that the Commission is not a ‘complaints agency’ and does not have statutory powers to investigate complaints. The Commission will use their powers of inspection to undertake enquiry so that we can make a judgement as to whether the provider is complying with the regulations. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 18 Records of complaints were said to be placed in the home’s complaints book, but no entries were found and Miss Phillips said that no complaints had been received since the last inspection. Survey work conducted by Commission for Social Care Inspection (CSCI) resulted in two responses from relatives, both stating that they had never made a complaint and that they were not aware that the home had a complaints procedure. This should be addressed to ensure that all parties are fully aware of the home’s complaints procedure and practice. A third response from a health and social care professional stated that they had never received any complaints about the home. Responses from all six service users said that they knew how to make a complaint, although three of the six said that they would require assistance from care staff to do this. One service user stated that they had a copy of the home’s complaints procedure. One new staff member interviewed at the site visit said that if they had any concerns or complaints they would refer them to the registered manager. At the site visit an adult protection procedure was found to be in place. This now requires revision and updating to include reference to the Essex County Council adult protection policy and the Protection of Vulnerable Adults (POVA) referral procedure. Miss Phillips was given guidance as to the latest information. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. (Adults 18-65) Quality in this outcome is is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the home provides a safe, well-maintained environment that is accessible to service users, homely and meets individual needs. EVIDENCE: 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 20 A tour of the premises was undertaken at the site visit. All of the accommodation was seen. There was a contrast in the contents of some service users’ rooms. For the majority of the service users there was an abundance of pictures, photographs and personal belongings on display, whilst for one service user this was not the position. Miss Phillips explained that this was related to their wishes and behaviour and although the room was sparse, efforts had been made to protect and display photographs in their room. The inspector was told that this practice was detailed and referenced in their care plans. Since the last inspection ongoing maintenance and decoration has taken place. One bedroom and en-suite had been decorated. There was however a smell of urine in this facility. The registered manager acknowledged this. A thorough clean and a more appropriate floor covering is to be considered. A programme and record of maintenance to the property is kept. Since the last inspection, the home has adopted a no smoking policy. Both service users and staff now smoke outside the building. Overall the gardens both front and back were well cared for. Miss Phillips said that the home employs a gardener and one of the service user’s mows the lawns. At the rear of the back garden an old discarded upright freezer and an old shed were found. Miss Phillips said that the shed, which was clearly in disrepair was not used and the freezer was to be removed. Both of these items should be removed for they were both unsightly and could present as a hazard. Miss Phillips said that neither the fire service nor the environmental health service have visited the home since the last inspection. Miss Phillips had an understanding of the need to complete a detailed fire risk assessment of the property and she was in the process of completing these assessments for the entire home. 17 Woodrows Lane has a compact laundry/utility room. This houses one washer and one dryer, both domestic. There is a sink unit for hand washing clothing and the ironing board and iron are stored here. Decoration was acceptable, although some attention will be required to wall surfaces, which have become worn. Miss Phillips was fully aware of this and action had been taken to prevent further wear. Hot water temperatures at wash hand basins and baths are checked and recorded. These were found to meet requirements with regard to water temperatures, but did not detail the location of the hot water taps checked. Miss Phillips acknowledged that this was the position and confirmed that amendments will be made to the records to detail this. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome is is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the home has a dedicated staff team and service users are protected by the home’s recruitment practices and training. EVIDENCE: 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 22 the registered manager. National Vocational Qualifications (NVQ) level 2 training is being progressed. Of the two staff files sampled, the inspector was able to see that one newly appointed care worker holds a NVQ level 2 in care and the second care worker is awaiting an assessor to proceed with the training. During the site visit, staff were seen to communicate well with the service users. They were good listeners and showed interested in their residents. Service users were involved in the activities going on during the day, or were allowed to do what they wished. Staff files were sampled and inspected for two care workers. Overall these records were well managed with evidence of identity, written references and qualifications. The one exception was the failure to hold a Criminal Record Bureau (CRB) disclosure for one care worker. Whilst it is recognised that this staff member is a new recruit, Miss Phillips was informed that all care workers must have an enhanced Criminal Record Bureau (CRB) disclosure before commencing work. She was advised to refer to the guidance on the Criminal Record Bureau (CRB) Website and the Commission for Social Care Inspection (CSCI) website. Of the two staff files sampled there was evidence of an in-house induction record on one staff file. Miss Phillips was advised of the need to ensure that there is a staff training and development programme, which meets Sector Skills Council workforce training targets. Consideration should be given to the Learning Disabilities Accredited Framework (LDAF) training and Skills for Care training programmes. Advice was given and Miss Phillips needs to progress this for all new staff members. Staff supervision has been introduced as was noted at the last inspection. Of the two staff files sampled one care worker was within their three-month probationary period and a supervision session had been completed and the second care worker had two recent supervision records. Discussion took place as to the development and programming of regular staff supervision sessions. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 24 37, 39, 41 and 42. Quality in this outcome is is adequate. This judgement has been made using available evidence including a visit to this service. The home has a competent manager to run the home. Overall, the home has developed a quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the service users. Safe working practices are promoted through ongoing training. Health and safety certification promotes a safe working environment. EVIDENCE: Miss Phillips told the inspector that she had started the Registered Manager’s Award in October 2006 and she is hoping follow this with the National Vocational Qualification (NVQ) level 4 in care, completing both courses in 2007/08. Having worked in the home for several years, and worked alongside the previous registered manager, Miss Phillips has a good understanding of her role and responsibilities. She spoke of the ways in which she had developed her management style and is hoping through this training and accumulated experience she will be able to further enhance the care offered at 17 Woodrows Lane. Quality assurance and quality monitoring systems have been developed within the home. Survey work has been completed by college tutors and from the results and feedback and discussion with service users, future college courses and attendance has been planned and actioned. In addition both visitors surveys and service user questionnaires have been used. From these findings a report has been completed. Some immediate action had been taken as a result of this survey work. Miss Phillips spoke of additional quality assurance work and the development of further this aspect of care. She said that the home had found it both enlightening and useful in caring for service users. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 25 Regulation 26 visits and reports were considered and inspected at this inspection. Whilst a copy of the September visit by the registered provider had been sent to the Commission for Social Care Inspection (CSCI), no copy was found in the home. The registered provider is reminded of the need to ensure that the registered manager is provided with a copy, so that there is discussion and progress as to the action to be taken. It should be noted however, that the content of this most recent report was brief and scant and did not give much insight into the matters considered and discussed at this visit. Further thought should be given to the detail of these reports. Safe working practices are ensured through basic training courses, close monitoring and supervision of care staff. Some evidence of training and staff supervision was seen on the staff files sampled and this was also confirmed by the registered manager and a care staff member. Since the last inspection care staff have attended training in basic food hygiene, infection control and all staff employed in August 2006 had completed Infection Control workbooks with health and safety. Two staff were attending fire extinguisher training on the day of the site visit and two care workers were booked on a one day accredited first aid training course. Care staff spoken to confirmed attendance at these training courses and were very positive with regard to training opportunities. 17 Woodrows Lane DS0000017723.V316291.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 Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 2 38 X 39 3 40 X 41 2 42 3 43 X 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 17 Woodrows Lane Score 3 3 2 X DS0000017723.V316291.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13, 14 Requirement The registered manager must review and revise service users’ risk assessments to ensure that they have good information on which to base decisions. The registered manager must ensure that all care staff have accredited training and this must include: • Basic knowledge of how medicines are used and how to recognise and deal with problems in use; and Timescale for action 11/12/06 2. YA20 18 (1) (c) 11/12/06 3. YA22 22 (4) (5) 4. YA23 13, 21 The principles behind all aspects of the home’s policy on medicines handling and records. The registered manager must review and revise the home’s complaints procedure to fully reflect the role of the Commission. The registered manager must review and revise the adult protection procedure, detailing DS0000017723.V316291.R01.S.doc 11/12/06 11/12/06 17 Woodrows Lane Version 5.2 Page 28 5. YA24 16, 23 6. YA34 19, Schedule 2 the local authority referral process and Protection of Vulnerable Adults (POVA) referral. The registered person must 11/12/06 ensure that the home’s premises are safe and well-maintained and free from urine smells. The registered person must 11/12/06 operate a thorough recruitment procedure, which includes completion of Criminal Record Bureau (CRB) disclosures before commencing employment. The registered person must ensure that there is a staff training and development programme, which meets Sector Skills Council workforce training targets. The Registered Person must ensure that the registered manager is qualified to run the home and meet its stated purpose, aims and objectives. This is with regard to obtaining a qualification in level 4 NVQ in both management and care. The Registered Provider must ensure that they conduct a visit and supply a copy of the visit report in accordance with Regulation 26. (This is a repeat requirement. Timescale of 27/06/05 and 30/12/05 not met.) 11/12/06 7. YA35 18 8. YA37 18 30/12/08 9. YA41 26 11/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 29 No. 1. Refer to Standard YA24 Good Practice Recommendations The registered manager should ensure that record keeping clearly details hot water temperatures and their locations of all wash hand basins and baths. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 17 Woodrows Lane DS0000017723.V316291.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!