Inspection on 11/07/05 for Bury Metro - Woodbury

This inspection was carried out on 11th July 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Bury Metro - Woodbury 30/07/07

Bury Metro - Woodbury 29/11/06

Bury Metro - Woodbury 20/01/06

Bury Metro - Woodbury 21/01/05

Bury Metro - Woodbury 16/07/04

Bury Metro - Woodbury 11/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 BURY M.B.C. - WOODBURY Wesley Street Tottington Bury BL8 3NN Lead Inspector Sue Evans 10 th & Announced 11 July 2005 th 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 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 Stationary 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. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodbury Address Wesley Street Tottington Bury Lancs BL8 3NN 01204 887424 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bury M.B.C. Mr Peter Miller CRH PC - Care Home Only 5 Category(ies) of LD Learning Disabilities registration, with number of places BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Staffing levels are to be calculated in accordance with the Residential Forum (Younger People) by 1 April 2004 The service should employ a suitably qualified and experienced manager who is registered with the Commission fo Social Care Inspection. Date of last inspection 21st January 2005 Brief Description of the Service: Woodbury is a Local Authority home providing care and support for adults who have a learning disability. The home provides three different services within one building. The semiindependent unit and the resettlement unit are registered as domiciliary care provision, and were not included in this inspection, which covered the four place short stay unit, and the emergency place. The short stay unit is on the ground floor. It is separate from the rest of the building and has its own entrance. The unit has exclusive use of a small lounge, dining kitchen, bathroom, and toilet. All bedrooms are single. Service users who are admitted in an emergency have use of a single bedroom on the first floor. They have use of the communal facilities used by those living in the resettlement unit. All service users are able to use the enclosed garden, and the relaxation room. The home is situated in the centre of Tottington, close to bus routes, shops, library, and other local amenities. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The findings in this report refer only to the home’s short stay service, and the emergency place. A separate report is available covering the resettlement and semi-independent units. This announced inspection was carried out by two inspectors over 2 days for a period of 13¼ hours each. On the first day, a Sunday, inspectors visited at 9.30am and spent 5½ hours in the home, looking round the building, watching what went on, talking to the 3 service users who were using the short stay unit, and interviewing the 3 Senior Residential Care Officers. During the second day, the inspectors spent 8¼ hours in the home, interviewing the Registered Manager, Deputy Manager, and Short Stay Senior, interviewing 2 staff members who regularly work within the short stay unit, and examining some key records. One inspector ate lunch with the residents. The CSCI Pharmacist Inspector also visited on the second day to look at the home’s medication procedures. Her findings were sent to the home in a separate letter. The letter is available, on request, to members of the public. Written comments were received from 3 of the people who use the short stay service, and 3 of the relatives. What the service does well: Assessments are carried out in conjunction with service users and their relatives. By including them in deciding what they need support with, and by finding out their likes, dislikes, and wishes, service users’ rights to make decisions about their lives are respected. Care plans are very detailed and give explicit guidance to staff members about how each service user is to be supported. Service users’ preferences are taken into account when planning their care. For instance, service users said that they could choose what time they get up or go to bed. Service users know that they can see their own care plans, and that these are updated if their needs change. Service users were pleased with the care and help provided. They said that their privacy was respected, and they were treated very well. One person said, “They treat me very well. They’re nice and polite including night staff”. Of the three service users and three relatives who provided written comments about the home, all except one said that they were satisfied with the care provided. Staff members were knowledgeable about the needs of the residents and they spoke with, and about, residents in a respectful way. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 6 Service users and staff feel that the manager is approachable. During the inspection, it was observed that residents and staff freely approached the manager. Service users feel that they can talk to staff about anything they wish and that they will be listened to. Staff members said that they received the support they needed to do their jobs and that they were encouraged to put forward their ideas. They feel that the team is well motivated. Thus, service users benefit from the open, inclusive, forward looking atmosphere within the home. What has improved since the last inspection? What they could do better: Although the home does its best, within the limits of its budget, to provide a comfortable, safe, and pleasant environment for service users, there is a need for some improvement in furnishings and maintenance. There is also a need to ensure that fire safety is promoted by making sure that the bedding storeroom is kept locked, and that all fire doors close fully to the rebate. To ensure the health and welfare of service users, the home needs to make arrangements for anyone who handles medication to go on a suitable training course. Staff members try to support people with community leisure activities whenever they can. However, a number of factors, including staff availability, mean that outside activities are not always possible, particularly in respect of unplanned, spontaneous outings. The home has therefore been asked to review the deployment of staff on the short stay unit with a view to looking at ways for service users to take part in community leisure activities more regularly. Protection policies ensure that the service has the means to be able to respond properly to any suspicion or allegation of abuse. However, to further promote the welfare of service users, this needs to be supplemented by providing suitable staff training on the topic. Given that a relative had said it was difficult to get through to the short stay unit by telephone, it would be useful if relatives were provided with an alternative telephone number, so that they can more easily contact members of staff even during times when the short stay unit is unoccupied. Staff rotas and some medication records need to be more detailed. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 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. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 The Statement of Purpose and Service Users’ Guide contain useful information about the home. They give prospective service users information that can help them decide whether the home is suitable. People coming to stay at the home have their needs, and compatibility with others, assessed and agreed with them so that they know what to expect of the service. The involvement of service users, and their relatives, in agreeing the assessment means that they have a say about how they would like staff to help them. EVIDENCE: Since the previous inspection, the Statement of Purpose and Service Users’ Guide had been updated. They contained useful information about the home including details of its facilities, the experience and qualifications of the staff, and a copy of the complaints procedure. One of the Senior Residential Care Officers said that the home planned to produce these documents in Urdu and large print. Three of the residents’ personal files were looked at. They showed that care management assessments had been obtained before a place was offered. The home had also carried out its own assessments, in conjunction with service users and relatives, to ensure suitability and compatibility for all concerned, and to make sure that the admission criteria was met. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 10 The home’s assessments were written from the service user’s perspective, and included the person’s likes and dislikes, how they liked to spend their time, and how they would like staff to assist them. The assessments were very detailed, with needs and wishes clearly recorded. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 Service users know that they can see their own care plans, and that these are regularly updated to reflect any changes in their needs and goals. The home encourages service users to be as independent as possible, helping them to keep any risks to their health and well being to a minimum. EVIDENCE: Each of the three personal files that were looked at contained very detailed care plans that gave explicit guidance to staff members about how each person was to be supported. The care plans had been developed from the information gathered during the assessment. Care plans included each service user’s preferences and goals, and reflected the home’s objective of encouraging service users to be as independent as possible. Service users, or their relatives, had signed their agreement to the care plans. Records showed that the care plans were updated every six months. The Short Stay Senior and 2 staff members were asked about the needs of the three service users. They were consistent in their descriptions of how they supported them, and this matched with information given by the service users. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 12 Two of the service users said that they knew about their written records and that they had attended meetings to discuss their support needs. Records showed that potential risks had been assessed, and balanced against the resident’s right to choice and independence. Risk assessments covered areas such as moving and handling, epilepsy, and general health and safety. Records showed that risk assessments had been agreed and signed by the service user or their relative. Personal files were tidy, and organised into sections. However, it would be easier to locate the most up to date information more quickly if it was stored at the front of the file. Daily report records were completed for each person. They included details of meals eaten, activities undertaken, and other general information related to the person’s needs. At the end of each service user’s stay at Woodbury, the home sent relatives a written summary of the visit. The Service users who were spoken with during the inspection said that they were happy with the support given to them whilst staying at Woodbury. One said, “They treat me really well. They’re nice and polite including night staff”. Of the 3 service users and 3 relatives who provided their views about the home in writing, all except one said that they were satisfied with the care provided. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 16 Whilst staying at Woodbury, service users are able to carry on with their usual weekday routines, enabling them to continue to take part in activities that they value and find fulfilling. During evenings and weekends, service users are able to pursue their chosen indoor leisure activities, although outside activities sometimes have to be preplanned. This can restrict spontaneity and choice. Practices in the home respect service users’ rights to privacy, dignity, choice and independence. EVIDENCE: Records, and discussions with service users and staff, showed that Woodbury worked closely with Social Workers, Day Services, and Colleges, to ensure that, during their stay at the home, service users were able to continue to attend their usual weekday activities. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 14 Service users’ interests and hobbies were determined as part of the assessment process, and social needs were included in care plans. Service Users talked about how they spent their time whilst staying at Woodbury. They said they enjoyed pastimes such as watching television or films, listening to music, and sewing. One service user said that they regularly went out with staff to the cinema, to Bury for shopping, or for a meal out. During the first day of the inspection, two of the service users went out with a staff member to the cinema, and the other service user went for a picnic to Burrs Country Park. Of the 3 service users who provided written comments, one said that the home provided suitable activities. One person replied “No” to this question, and the other person did not answer it. Staff members said that they tried to accompany people on outdoor activities when possible. However, they said that this could depend upon the wishes of the service users, the level of the individual’s support needs, and the availability of staff. One said that outside activities often had to be planned ahead, and could not always be arranged spontaneously. The Short Stay Senior said that the home tried to arrange at least one outside activity each weekend. Individual daily records included details of the activities undertaken. Care plans contained details of service users’ preferences in respect of their daily routines. Service users said that they could choose what time they got up or went to bed, and that they could choose how they spent their time. They gave examples of how staff members encouraged and helped them to do things for themselves, for example make a drink, or help with the washing up. Staff members gave examples of how privacy and dignity were promoted in the home, for instance when attending to personal care. Residents were satisfied that their privacy was respected, for example nobody entered their bedrooms without knocking. Locks were fitted to bedroom doors, and service users said that they could have a key if they wanted to. It was observed that staff members and service users spoke with each other in a natural, friendly manner. Service users said that staff treated them with respect. All three of the service users who provided written comments said that their privacy was respected, and staff treated them well. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Medication storage and procedures are generally satisfactory and promote good health and safety but there is a need for accredited medication training for some staff, and some additions to medication records and policies. EVIDENCE: On the second day of the inspection, the Pharmacist Inspector visited the home to look at medication procedures. Full details of her findings were contained in a letter that was sent to the home. The letter will not be published but it will be made available, on request, to members of the public or other enquirers. Policies and procedures describing the handling of medication needed reviewing and updating. None of the service users self-administered any of their own medication. However, not all care staff who handle medication had completed accredited training in the safe handling of medication. This needs to be addressed. One service user who had difficulty swallowing needed to have their medication with food. Advice was given about the need for this to be clearly stated in the care plan. The home was also asked to make sure that the medication was BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 16 suitable to be given in this way, and to obtain signed agreement from the family, carers, and health professionals involved. The home was asked to ensure that lists of current medication, completed by service users’ representatives, were dated. Medicine administration records were up to date. Records were kept of medication received into, and leaving, the home. It was recommended that both the receipt and returns records be signed. Medication was securely stored. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a written complaints procedure, and residents feel that any concerns will be listened to and dealt with. Protection policies ensure that the service has the means to be able to respond properly to any suspicion or allegation of abuse. However, to further promote the welfare of service users, this needs to be supplemented by providing suitable staff training. EVIDENCE: The home has a written complaints procedure. The relatives who provided written comments said that they were aware of the procedures. Residents said that they knew who to speak to if they had any concerns. They gave examples that showed that they were comfortable about raising matters of concern, and they felt that they were listened to. There were written procedures covering Adult Protection and Whistle Blowing. Staff members who were consulted during the inspection said that they were aware of them and had looked at them briefly. They understood their responsibilities in respect of reporting their concerns to a manager. One said that they recalled these topics being discussed during a staff meeting. However, the staff members had not received any training in these topics. The Deputy Manager said that he had been looking into suitable courses. If a suitable course is not found, the home is asked to check out staff understanding of these topics by means of discussions in 1 to 1 supervision meetings, and perhaps by use of in-house videos and questionnaires. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28, 29 and 30 Although the home does its best, within the limits of its budget, to provide a comfortable, safe and pleasant environment for service users, there is a need for the Responsible Individual to ensure that the budget is enough to enable satisfactory standards to be achieved and maintained. EVIDENCE: The home is situated in the centre of Tottington, close to bus routes, shops, and other local amenities. The short stay unit is on the ground floor. It is separate from the rest of the building, and has its own entrance. The unit has exclusive use of a lounge, dining kitchen, bathroom and toilet. All bedrooms are single. Any service user admitted in an emergency has a single bedroom on the first floor. They also have use of the communal facilities used by those living in the resettlement unit. The enclosed garden provides a pleasant setting where people can sit out in nice weather. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 19 Efforts had been made to make the short stay lounge homely and comfortable. However, the lounge suite was badly stained and needed replacing or recovering. Bedrooms had been individually decorated in different colour schemes. The service users who were spoken with during the inspection said they were satisfied with their rooms. They had brought in some of their own possessions to make their rooms more homely. Rooms contained basic furnishings. Wardrobes, drawers and vanity units were looking “tired”. Although the home had done its best to brighten them up by painting them, they were barely adequate. One of the relatives who provided written comments felt that the home was “shabby.” Inspectors were of the opinion that the home was doing its best, within the limits of its allocated budget, to create as pleasant an environment as possible for service users. However, there is a need for the Responsible Individual to ensure that the budget is enough to enable satisfactory standards to be achieved and maintained. Other work needing attention is included under the requirements section of this report. It includes the re-varnishing of doors, attention to door closures on some doors that were not closing to the rebate, and the need for the bedding store to be kept locked. The home was fitted with adaptations and equipment suited to the needs of the service users. These included grab rails, portable hoists, assisted bath, shower, ramps and assistance call system. Key pads were placed at entrances to the short stay unit to aid security. Bedroom doors were fitted with alarms. There was no passenger lift, so anyone using the “emergency” bedroom would need to be able to use the stairs. Standards of cleanliness in the home were satisfactory. Liquid soap and paper towels were provided for hand washing in communal areas. Laundry facilities were satisfactory. Items of clothing were booked in and out by staff. However, the Short Stay Senior was aware that sometimes items of clothing went missing, or might be damaged in the wash. The home has a policy of replacing such items. The Short Stay Senior said that this was an area that she would be looking at to see how it might be improved. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Whilst staffing levels are sufficient to meet the personal and health needs of the residents, it is not always possible to provide spontaneous outside activities. EVIDENCE: Planned staffing numbers met requirements. In addition to care staff, the home employed a cook, an administrator, a maintenance worker, and a domestic worker. The nature of the short stay service means that staffing needs to be flexible in order to meet the needs of the constantly changing mix of service users. The short stay unit had a senior officer and four key workers. During each shift, a designated worker was assigned solely to the short stay unit. This worker was assisted at key times (for example when people were getting up) by a second support worker who divided their time between the short stay unit and the semi-independent unit. This system seems to work in respect of attending to service users’ personal needs, but it does not always result in the unit being sufficiently staffed to enable spontaneous outside activities to take place (see section in this report under “Lifestyles”). Some staff, service users, and relatives did not think that there were always enough staff on duty. Staff members said that the home had experienced some problems, with staff sickness and unfilled vacancies, which sometimes affected planned staffing levels. One of the service users who provided written BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 21 comments said that, “ The staff are great but always understaffed, so struggle to take people out or spend leisure time with them”. All three of the relatives who provided written comments felt that there were insufficient staff. One said that telephones were not answered, and that they could never find anyone to talk to. However, staff members explained that the short stay unit had a separate telephone number from the other units. Consequently, when there were no service users present on the unit, there would be no staff to answer calls. Discussion took place about the need to find a solution to this problem, perhaps by providing people with Woodbury’s other number. There had recently been a re-organisation of the roles of the senior staff at Woodbury. The present Short Stay Senior had taken over responsibility for the Unit only a few months before the inspection. She said that she was intending to liaise with relatives to try to build up relationships and develop a more inclusive way of working. The home was asked to make sure that staff rotas contained surnames. Where agency workers are used, this needs to be clearly stated on the rota. The home also needs to obtain written confirmation from the agency that the required recruitment checks have been done. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 and 42 Service Users benefit from the open management approach of the home and they are able to openly express their wishes and opinions. The health and safety of service users and staff are promoted by means of regular maintenance and safety checks, EVIDENCE: It was clear, from observations and discussions, that the Registered Manager encouraged an open, inclusive atmosphere within the home. Staff members said that the manager was approachable, supportive, and encouraging. They said that ideas were listened to. They felt that the staff team was well motivated. One person said that the manager encouraged creativity and development, and that there was room for “positive disagreements”. Staff members said that regular staff meetings took place where there was an open agenda, and suggestions and comments were welcomed. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 23 During the inspection, it was observed that service users and staff had no hesitation in approaching the manager if they had anything they wished to discuss. Records showed that the home took steps to promote the health and safety of residents and staff. Maintenance records were up to date. Those examined included gas soundness, electrical installation, portable electric appliance tests, servicing of portable hoists, Legionnaire testing, and servicing and standard checking of fire alarms and fire equipment, and emergency lighting. BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 2 3 x 3 x Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 BURY M.B.C. - WOODBURY Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 25 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 20 Regulation 13(2) Requirement The home must address the requirements set out in the Pharmacist Inspectors report which states that staff members who handle medication must be enrolled onto a certificated medication course. The home needs to ensure that staff members receive appropriate training in adult protection. The Responsible Individual must provide the CSCI with written information about future refurbishment plans for the short stay and emergency units, including the replacement of the wardrobes, drawers and vanity units. The lounge suite in the short stay unit needs replacing or recovering. The home must ensure that all fire doors close fully to the rebate. Some doors need re-varnishing. Timescale for action 3 October 2005 2. 23 13(6) 30 November 2005 30 September 2005 3. 24, 26 16(2)(c) 4. 5. 6. 7. 8. 24 24 24 24 33 16(2)(c) 23(4) 23(2)(d) 23(4) 19 30 November 2005 31 August 2005 31 October 2005 The bedding storeroom must be 11 July kept locked. 2005 In respect of agency workers, 11 July the home needs to obtain written 2005 Version 1.40 Page 26 BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc 9. 33 17 confirmation from the supplying agency, prior to the worker commencing duty, that the required recruitment checks have been completed. Staff rotas must include full names. Where an agency worker has been rostered, this must be clearly stated. 31 August 2005 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 6 13, 33 Good Practice Recommendations The home is advised to re-organise service users personal files so that the most up to date information is located at the front. The home is asked to review how staff are deployed in the short stay unit with a view to enabling them to support service users in leisure activities in the community more often. The home is advised to act upon the recommendations set out in the Pharmacist Inspectors report in respect of more detailed record keeping. The home is advised to provide relatives with an alternative telephone number, so that they are able to contact members of staff even during times when the short stay unit is unoccupied. 3. 4. 20 33 BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton, BL6 6HG National Enquiry Line: 0845 015 0120 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 BURY M.B.C. - WOODBURY F56 F06 S53090 Woodbury V215563 100705 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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