Inspection on 30/07/07 for Bury Metro - Woodbury

This inspection was carried out on 30th July 2007.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bury Metro - Woodbury 29/11/06

Bury Metro - Woodbury 20/01/06

Bury Metro - Woodbury 11/07/05

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 Metro - Woodbury Woodbury Wesley Street Tottington Bury Lancs BL8 3NN Lead Inspector Julie Bodell Unannounced Inspection 30 July & 6 August 2007 09:30 th th Bury Metro - Woodbury DS0000053090.V337678.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 Bury Metro - Woodbury DS0000053090.V337678.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. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bury Metro - Woodbury Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Woodbury Wesley Street Tottington Bury Lancs BL8 3NN 01204 887424 Bury M.B.C. Mr Peter Miller Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 29th November 2006 Date of last inspection 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 preindependence 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 only. 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 Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection which the home was not told about beforehand took 7 hours alongside the inspection of Woodbury Accommodation Domiciliary Care Agency. During the inspection the inspector spent time talking to two senior support workers, two support workers, watched what went on in the home, talked to a service user and looked at paperwork. The inspector requested pre-inspection information, which was received from the home. Survey responses were also received from seven service users and their relatives. What the service does well: What has improved since the last inspection? All service users and their families have been allocated a named key worker. To improve communication, annual home visits have been re-established and a second home visit to the homes of regular users or a telephone courtesy call, have been introduced. A photograph of the service user has been put with the MAR sheet to ensure that medication is administered to the correct person. Service users families or representatives have been given a copy of the complaints procedure so that they know how to make a complaint about the service. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 6 The bedroom doors that allow access to the lounge and dining kitchen areas have been blocked off to improve privacy and create the appearance of more space. Wardrobe doors and sink units in the bedrooms have been refurbished as well as new furniture purchased and new floor coverings put down. A dedicated named staff team has been identified for the respite unit to help ensure that sufficient, consistent and flexible support is available to service users. The Home’s electrical fitment and fittings have been checked to ensure that they are safe. 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. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 7 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 Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 8 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are assessed prior to an admission being agreed to ensure that their needs can be met. EVIDENCE: Woodbury short stay unit provides care and support for up to four service users at anyone time. There are currently thirty-eight people accessing the service, twenty on a regular basis. Service users have a diverse range of needs from profound and complex needs requiring a high level of support to minimal support. Two of the service users care files were looked at. They show that community care assessments had been carried out by a qualified social worker and obtained before a place was offered to ensure that the service was able to meet their needs. Following completion of an application form to use the service, a support worker from the home carries out a more detailed assessment, in conjunction with service user and their relatives, to ensure suitability and compatibility for Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 9 all concerned, and to make sure that the admission criteria was met. The 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 support workers to assist them, with needs and wishes clearly recorded. There are generally four service users using the short stay facility at the weekends and two or three during the week. Arrangements are made on the basis of level of need and compatibility. A small number of service users receiving one to one support during their stay at the home. The senior support worker said that the service could meet the needs of all service users coming into the home at this time, safely. Improvements have been made recently to the service. These include a new senior support worker to oversee the day-to-day running of the respite unit. The senior support worker is currently undertaking introductory home visits to service users homes. All service users and their families have been allocated a named key worker. Due to an increase in identified staff on the respite unit, annual home visits have been re-established and a second home visit to the homes of regular users or a telephone courtesy call, have been introduced. These visits are important to ensure good communication links between the service users, their family and Woodbury are maintained so that the home can be kept updated around the changing needs of the service user and check out that the service user and their family are happy with the quality of service that they are receiving. The inspector observed two service users being admitted to the home for a period of respite care. One service user was very anxious about coming into Woodbury. Support workers were seen to gently encourage the service user offering constant reassurance and kind words. Both service users were able to chose which room they wanted to use during their stay. At the end of each service user’s stay at Woodbury, the home sent relatives a written summary of the visit. One returned survey from a service user stated that, “I enjoy and look forward to going to Woodbury for the weekend – I usually go one weekend in four.” The emergency bed was in use and had been for sometime. There are plans in place for the service user to move to a new house. The service user has been undertaking gradual introductory visits to the new property and making friends with the service users that live at the house and this is ongoing. The senior support worker said that the service user has been able to convey their approval of the move. Bury Metro - Woodbury DS0000053090.V337678.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user plans were in place and these are updated to reflect any changes in their needs and goals. The home encourages service users to be as independent as possible during their stay. EVIDENCE: Service users who use the short stay unit or emergency place live at Woodbury for respite only. Any major decisions about their lives would therefore tend to be made by their families or other representatives. The care files looked at contained detailed care plans that gave guidance to support workers about how each person was to be supported. The care plans had been developed from the information gathered during the assessment and covered areas such as medication, mobility, communication, health care issues, dietary needs, personal hygiene, activities, money, allergies, vision, Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 11 hearing, oral health and dental care etc. 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 and this was observed throughout the inspection. Service users, or their relatives, had signed their agreement to the care plans. Records showed that the care plans were reviewed annually. Discussions with support workers about the service users were consistent with the service users’ care plan and how they were to support them. Support workers spoken with knew service users well. Potential risks had been assessed, and balanced against the resident’s right to choice and independence. Risk assessments covered areas such as use of the kitchen, bathing, maintaining health, moving and handling, epilepsy, and general health and safety. 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. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 12 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): 12 13 15 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst staying at Woodbury, service users are able to carry on with their usual weekday routines. During evenings and weekends, service users’ are able to pursue their chosen indoor leisure activities but opportunities for outside activities sometimes have to be pre-arranged for people needing support. EVIDENCE: Discussion with support workers showed that Woodbury worked closely with 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. Many service users are transported to Woodbury straight from local day centres and return home via the day centre. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 13 Individual daily records include details of the activities undertaken. At previous inspections concerns have been raised at the lack of availability of staffing for service users to go on outside activities for those requiring support. Outside activities generally have to be planned in advance and cannot always be arranged spontaneously. Now that there is a dedicated staff team for the short stay, support workers said that there where more opportunities for service users to go on outside activities more often. It was clear from the records of a service user going home from Woodbury that a number outside activities had taken place. Over the weekend the service user looked up the cinema on the Internet and chose to see the film Hairspray. They had been out for a drive and to the pub with friends. Outside activities would not have been possible on the evening of the second visit for service users. There was a one to four ratio of support worker to service users three of whom had profound or complex needs. However, service users were enjoying watching the “soaps” on television. At the last inspection the pending recruitment of seven support workers, was hoped to improve this situation but unfortunately due to a number support workers retiring or leaving to go to other posts the vacant staffing hours is back to 130 hours, which is in the main being covered by care pool or outside agency. A good rapport was observed between the support workers and service users and the atmosphere was relaxed and friendly. A service user said that they liked all the staff team at Woodbury. Relatives and friends are able to visit service users during their stay at Woodbury. Some service users liked to maintain contact by telephone. A returned service user and relative survey commented, “ The staff are extremely polite and helpful, they are also very caring.” Another stated, “I have found that the staff are great. They listen if you are worried about anything and my son gets on very well with the staff.” Service users have there own small kitchen/dining room. There are facilities to make drinks and small meals like breakfast and snacks. Service users were encouraged to prepare breakfast were able and helped to prepare packed lunches for the centre. The main meal of the day is made in Woodbury’s catering kitchen. From a service user’s records it was clear that there were choices of meals available. A selection of meals eaten by the service user over the weekend were minted lamb, new potatoes, carrots and peas, a welsh bake followed by cheesecake and chicken curry with salad and fruit. The service user said that they enjoyed their meals and that they got enough to eat. There is a list of dietary needs for short stay users that identifies allergies, problems, dislikes and how the service user is to be supported. The inspector looked at the main kitchen at Woodbury. There are two cooks now in post at Woodbury. There are generally two or three choices of meals including a vegetarian option. The cooks use the Safer Food Better Business documentation. The kitchen needs to be painted as soon as possible to both improve the appearance and levels of hygiene. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 14 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. The home liaises with families to ensure that health needs are met and service users receive personal care in a discreet manner. EVIDENCE: Service users were able take to care of there own personal care needs with help from support workers if they needed it. Support workers were observed to assist people in a discreet manner, e.g. ensuring that doors were kept closed. Families generally take responsibility for making health care appointments. Support workers monitor service users health during their stay. If there was a cause for concern then the service users family would be contacted, or the home would contact the GP, BARDOC, NHS Direct or take to hospital if necessary. All support workers currently working on the short stay unit have received medication training. The medication system was generally in good order. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 15 Relatives usually dossette medication, that service users bring in with them and support workers book them in. There was a discrepancy noted in the transcribing of the medication. Medication is stored in a lockable cabinet. Photographs identifying service users have been added to their medication record to ensure that medication is administered to the correct person. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a written complaints procedure so as to ensure the views of the service users are listened to and acted upon. All the staff team need to undertake training in adult protection procedures to ensure that they know what action to take to protect people should an allegation of abuse occur. EVIDENCE: The home has a written complaints procedure, which is available to service users. Following the last inspection relatives have been provided with a copy of the complaints procedure. There have been no complaints about the service. The home has written procedures covering Adult Protection and Whistle Blowing. The subject also forms part of the Learning Disability Award Framework training. A senior support worker has attended a trainer’s training course to enable her to train other staff in adult protection procedures. Unfortunately due to staff shortages this has not been able to be completed. The CD and worksheet package was discussed. The package is clear around definitions and indications of abuse but less so around what action should or should not be taken by a staff member if a situation regarding abuse comes to their attention. This needs to be looked at by the organisation to ensure that the present training is adequate. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the appearance of the home to make the short stay unit homely and comfortable for people who use the service. 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 small 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. There was no passenger lift, so anyone using the emergency room would need to be able to use the stairs. Service users 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 Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 18 Ongoing efforts have been made to make the short stay unit safe, homely and comfortable and the general appearance has improved. Since the last inspection the bedroom doors that allow access to the lounge and dining kitchen areas have been blocked off to improve privacy and create the appearance of more space. Wardrobes doors and sink units in the bedrooms have been refurbished as well as new furniture purchased and new floor coverings put down to good effect. Bedrooms were individually decorated in different colour schemes, and service users brought in a few of their own possessions to make their rooms more homely. A relative stated in a returned survey “Whenever we have visited it has been a lovely environment.” The home is fitted with adaptations and equipment suited to the needs of the service users. These included grab rails, portable hoist, an assisted bath, ramps and assistance call system. Keypads were placed at entrances to the short stay unit to aid security. Bedroom doors were fitted with alarms. Standards of cleanliness in the short stay unit were good. Liquid soap and paper towels were provided for hand washing in communal areas. A hand washbasin needs to be put in the bathroom to improve hand-washing facilities for support workers. Disposable gloves and aprons are available to support workers. A relative stated, “It is always clean.” Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 19 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): 32 33 34 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Support workers need to be recruited quickly to ensure that there are enough support workers in post to assist service users. Arrangements have been made for support workers to receive outstanding training to ensure the health and safety of service users through good practice. EVIDENCE: It was noted that there was now a dedicated staff team for the short stay unit and there has been a significant improvement in continuity for service users and their relatives using the service. But the unit is still reliant on resettlement unit for support at times and this impacts on staffing available to tenants during these periods. Woodbury and Woodbury Accommodation in total employ thirty-three support workers, which include waking night staff, a cook, two domestic assistants and a handyman. There are also five managers and a part-time administrator across the three services that fall within Woodbury and the respite unit. At the last inspection the inspector was informed that 7 support workers were in the process of being appointed. This in the main was achieved. However, at this inspection Woodbury is back to Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 20 square one due to a number support workers retiring or leaving to go to other posts. At this inspection there were five vacancies totalling 130.30 hours, which represents approximately 20 of the overall staffing arrangement. The care pool team continues to be increased and provides the majority of the cover needed, to ensure continuity and consistency for the service users and tenants as far as possible. The registered manager will be advertising these posts in the near future. A discussion was had with the registered manager about the present budget arrangements for advertising posts and the cost effectiveness of advertising single posts against the need to ensure sufficient support workers are available to service users at all times. This area needs to be looked at by the organisation to see if improvements can be made so that recruitment of staff is quicker. A new senior support worker started in the New Year following induction training, and a second cook has also been appointed. The local authority care pool supplies most of the support and ensures that the service users get some continuity. Outside agency staff are accessed through the new Comensura system. Though rarely used on the short stay unit, the registered manager was reminded that all outside agency staff must meet the requirements of Regulation 19 Schedule 2 and that this must be evidenced at the point the support worker comes to work for the home. Only eight support workers had completed NVQ training with a further three currently undertaking the course. This does not represent 50 of the total staff team. An analysis of training needs has been carried out. It shows that 85 of the mandatory training needed to be undertaken by the staff team has been completed. Mandatory training includes basic food hygiene, health and safety, control of infection, first aid, moving and handling and medication training. Arrangements are being made where shortfalls in mandatory training have been identified to ensure the health and safety of service users. New support workers undertake mandatory training as part of the Learning Disability Award Framework induction programme. A senior support worker is on the final year of Diploma in Social Work and another senior starts the course in September. Computer training has been provided for some support workers and more information is received and held electronically, which has improved the standard and appearance of paperwork. A support worker spoken with said that the senior support worker was “very supportive and approachable” and that she had regular formal supervision. There were regular short stay meetings and a better sense of a team for the unit. The registered manager closely monitors that supervision sessions take place. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 21 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 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and they are able to openly express their wishes. Service users and others are asked for their views on the quality of the service they receive. EVIDENCE: The manager is registered with the CSCI. He has been manager of Woodbury since 1992. He holds the Certificate in Social Service qualification and the Registered Manager’s Award. From discussion, it was evident that the manager encouraged an open, inclusive atmosphere within the home. A deputy manager and three senior support workers, who have delegated responsibility for the three areas of service, pre-independence, resettlement and respite, Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 22 support the registered manager. It was clear from this inspection that there had been moves to start to operate the home as three distinct services. Senior support workers felt that the service had become more proactive, cohesive and better organised. There was the start of a long-term strategic plan for the service, which had led to clearer direction and focus. It was agreed with the registered manager that hours he worked would be recorded on the rota. Monthly Regulation 26 visits that should be undertaken by a representative of the responsible individual have not been undertaken for sometime due to ill health. These must be resumed as soon as possible. Quality assurance checks were carried out with a record of visit and comments being requested from service users about whether they enjoyed their stay at Woodbury. The inspector spent time talking to members of the management team about the process for Inspecting for Better Lives, including KLORA, quality ratings, annual reviews and AQAA, so that people would be clear about inspection process and what we would be looking for to produce an overall quality rating for the service. It was clear from discussion that staff at Woodbury, were consulting and involving service users and their families at times and acted on the findings, the file had been moved and was offered on the next visit but was not required. A quality review of the service needs to undertaken that will inform the planning process for the home and demonstrate quality of life outcomes for service users using the service. Maintenance and service checks were examined. These included clinical waste, emergency lighting, portable electrical appliances, gas, hoists and assisted baths and were found to be in good order. The fire record book needs to be checked, and out of date or no longer relevant information needs to be archived to make it more user friendly. The staff team have not received fire safety training and the fire risk assessment needs to be reviewed. Care must be taken to ensure that good practice is maintained when following control of infection and COHSS procedures. A significant number of out of date skin emollient spray canisters were found throughout the building, some without any labelling. These were removed throughout the inspection, as was communal soap, a number of chemical sprays, as well as old razors, to ensure the health and safety of service users. Only those staff members with up-to-date training should be using the hoist including care pool and outside agency staff. Regulation 37 notifications where discussed with the senior support worker to ensure that they were clear about notifying CSCI about serious incidents. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 23 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 X 2 3 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 YA17 Regulation 23 Requirement That the main kitchen is painted to improve the overall appearance and hygiene of the kitchen. To protect service users all the staff team need to undertake vulnerable adults procedure training that ensures that they are clear about what action they must take should an allegation of abuse occur. To improve hand-washing facilities for support workers a hand washbasin needs to be fitted in the short stay bathroom. The registered person needs to continue to encourage and support staff members with NVQ training with a view to having at least 50 of workers with the qualification. (Outstanding) That there are an appropriate number of suitably skilled and experienced support workers to ensure adequate staffing levels for tenants and service users across all units. The registered manager must ensure that all outside agency staff must meet requirements DS0000053090.V337678.R01.S.doc Timescale for action 31/10/07 2. YA23 13 31/12/07 3. YA30 23 31/10/07 4. YA32 18 31/03/08 5. YA33 18 30/09/08 6. YA34 19 31/08/07 Bury Metro - Woodbury Version 5.2 Page 25 7. YA35 18 8. 9. YA39 YA39 26 24 10. YA42 23 11. YA42 13 12. YA42 13 and that this must be evidenced before the staff member comes to work for the home. That identified gaps in mandatory training are carried out by the registered manager, seniors and support workers at Woodbury and each house to ensure that all tenants needs, can be safely met. That the registered provider or representative visits the home in accordance with this regulation. That a review of the quality of care is undertaken, a report produce and a copy forwarded to CSCI. (Outstanding) The fire record book needs to be checked, and out of date or no longer relevant information needs to be archived to make it more user friendly. To ensure the safety of service users, the staff team must receive fire safety training and the fire risk assessment must be reviewed and updated. The staff team must adhere to control of infection and COHSS procedures to ensure the health and safety of service users as identified in the body of this report. To ensure the health and safety of tenants only those staff members with up-to-date training use the hoist. 31/12/08 30/09/07 31/12/07 30/09/07 31/08/07 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000053090.V337678.R01.S.doc Version 5.2 Page 26 Bury Metro - Woodbury 1. Standard YA13 That there is enough staff time available to support service users outside the home, including evenings and weekends. Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Bury Metro - Woodbury DS0000053090.V337678.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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