CARE HOME ADULTS 18-65
The Oaks / Woodcroft The Oaks / Woodcroft 2a Dereham Road Mattishall Dereham Norfolk NR20 3AA Lead Inspector
Debby Allen Key Unannounced 10th May 2007 08:30 The Oaks / Woodcroft DS0000027492.V339640.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 The Oaks / Woodcroft DS0000027492.V339640.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. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Oaks / Woodcroft 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) The Oaks / Woodcroft 2a Dereham Road Mattishall Dereham Norfolk NR20 3AA 01362 858040 01362 858954 oaks.woodcroft@craegmoor.co.uk www.craegmoor.co.uk Conquest Care Homes (Norfolk) Limited Mrs Karen Elizabeth Bash Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th May 2006 Brief Description of the Service: This service is situated in a village some 15 miles or so west of Norwich city centre. It is set back from the road and consists of two bungalows, known as The Oaks and Woodcroft. The bungalows each have accommodation for six adults between the ages of 18 and 65 years and who have a learning disability. The Oaks tends to accommodate people with additional physical disabilities. Every resident has their own bedroom, which they can personalise and there are shared lounges, a dining room, bath/shower rooms, toilets and kitchens. The bungalows share a large garden to the rear of the properties and there is car parking to the front. The garden, which has relaxing swing seating and barbecue equipment, is safe with a secure perimeter. The home is owned and managed by Craegmoor Healthcare On the day of the inspection the home had no vacancies. Fees range from £781 to £2,097 per week. This information was provided by the home in a pre-inspection questionnaire, which was returned to the Commission on 29th March 2007. Inspection reports are available on request from the home. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This inspection was carried out over a period of seven hours, during which time a number of records were examined including care plans, personnel files, policies, procedures and information relating to health and safety. A tour of the premises was also undertaken and discussions were held with members of staff, including the manager and service users. Seven relative’s questionnaires were returned prior to the inspection, which contained comments such as:“Whenever we go to Woodcroft there is a very fine atmosphere and all there seem to be happy and well cared for.” “Since my relative has been living at The Oaks/Woodcroft, their social skills have improved.” “I think my relative has a good quality of care and the carers always inform us of any health issues etc.” “Friendly, listen to the residents and very good carers.” Six service users’ also returned completed questionnaires, which contained responses to ‘what’s good about living at your home’ such as:“Seeing staff, visiting the other bungalow, listening to my radio, the manager. “Going to dances, Sunday roasts, going for walks, having a long soak in the bath.” “Watching own TV, doing lots of different things, going out for meals, holidays and day centre.” One recommendation has been made as a result of this inspection. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? 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. The Oaks / Woodcroft DS0000027492.V339640.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 The Oaks / Woodcroft DS0000027492.V339640.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): 1, 2, 3 & 5 Quality in this outcome area is good. Service users and their family are provided with various forms of information, to ensure they are able to make an informed choice about where to live. Full needs assessments are carried out before people move in and they are assured that the service will meet these needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new admissions for a number of years, but the care plans that were examined contained evidence that full needs assessments have been carried out prior to people moving in. These assessments are reviewed and updated, as necessary, to help ensure people’s ongoing and changing needs continue to be met. Each person has a copy of the service user guide and service contract, which include alternative formats such as pictures, to help people to understand the information. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Quality in this outcome area is good. Care plans contain assessments of needs, wants and choices and are regularly reviewed and updated as necessary. Service users are actively involved in all aspects of life in the home, their views are taken into consideration and they are supported to make decisions and take risks. Service users’ information is secure and confidentiality is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were looked at in detail and each of these contained very clear and comprehensive information with regard to how people wanted and needed to be supported in their daily lives. One person’s needs, in particular, have changed considerably over the last few months and evidence of regular
The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 10 and ongoing reviews showed how the service was continuing to meet their needs. Some of the sections which made up the care plans as a whole, were as follows: Essential Information – likes and dislikes (including food and drink), activities (community based and external), Person Centred Plan, personal assessment (including personal history). Care Plans – these included problems or needs, aims to achieve and care intervention. Risk Assessments – these were seen to be up to date, relevant and reviewed regularly. Day Care Notes – these were informative and written using appropriate language to describe activities undertaken. Residential Notes – this section included references to friends and family contact and involvement. Reviews and Contact sheets – these included contacts and information from other healthcare professionals. Evidence of regular residents’ meetings was seen and notes from these meetings included the action that would be taken, which confirmed that service users are consulted on and participate in all aspects of life in the home. One example of this is that during one meeting, it was commented that a bird table and feeders would be nice in the garden and one person in particular said they would like to feed the birds. The outcome was that a table and feeders were purchased and the service users are able to watch and feed the birds as they wish. Risk assessments were very clear and covered all aspects of daily life. Although a few of these were generalised, a good many were very ‘person specific’ and were compiled with a very enabling attitude – i.e. supporting someone to do as much for themselves as possible, rather than doing everything for them. Some individual examples seen were people making hot drinks, cooking, household tasks and personal hobbies and activities. Service users’ information was seen to be stored securely in the manager’s office, thereby ensuring confidentiality is maintained. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 11 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): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. Service users have opportunities for personal development, are part of the local community and engage in appropriate leisure activities. Service users are supported to have appropriate personal relationships. Service users are offered a healthy diet and enjoy their meals and mealtimes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection a number of people were observed preparing and leaving for their daily activites, which included a day centre, boat trip and lunch out. The people at The Oaks/Woodcroft are very much a part of the local community and a number of people have friends or family living locally.
The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 12 Some external and community activities were seen to include going to the pub, restaurants, theatre, cinema, dances, bowling, circus, church and football in the local community. Evidence of leisure interests and hobbies was noted from a number of sources including service users’ and relatives’ questionnaires, care plans, in-house surveys and observations on the day. Some of these included Music, shopping, bird watching, swimming, jigsaw puzzles, bus rides, cycling, football, dancing, horse-riding, sailing, walking or just sitting quietly. Ensuring that service users are able to maintain personal relationships is something that the staff team, as a whole, consider to be extremely important and evidence of this was seen in care plans, in-house surveys and comments from relatives such as: “If my son wishes to speak to us on the telephone, the staff readily comply with his request. They are also helpful when he spends a weekend with us.” “I am unable to travel, but my relative visits me regularly.” Where possible, service users are involved in day-to-day tasks such as tidying their own room, doing their own laundry, washing up, tidying the dining room after meals, setting tables at mealtimes, cooking and making pots of tea. The menus and food diaries that were looked at showed a good variety of meals, which were wholesome, nutritious and generally home-made. Alternative choices are always offered, which are equally appetising and nutritious. Vegetarian options were also seen to be available and there was additional evidence to show that the home can and does respect and cater for specific dietary requirements regardless of whether they are through choice or for health, religious or cultural reasons. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 13 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, 20 & 21 Quality in this outcome area is good. Service users receive personal support in the way they prefer and their physical and emotional healthcare needs are met. Service users are protected by the home’s policies and procedures for dealing with medication. Service users are treated with dignity and respect with regard to ageing, illness and death. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans looked at were found to contain very detailed information about each person as an individual and how they needed and wanted to be supported. Communication can be an issue in certain circumstances and so a lot of time and effort has been spent compiling the care plans to ensure a consistent approach is maintained with regard to supporting each person. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 14 Information gathered from an in-house survey showed that people are able to choose what time they get up in the morning and what time they go to bed at night. This information also gave a summary of people’s needs with regard to whether they need full or partial support with personal care and hygiene. There was evidence on file of input from external healthcare professionals such as GP, community nurse, physiotherapist, speech & language therapist, chiropodist, dentist, optician, psychiatrist and occupational therapist. None of the service users are currently self-medicating, but the home does have robust policies and procedures in place with regard to handling and administering medication and staff are well trained in this area. The medication folder contains a front sheet for each service user, which includes their photograph and a medication profile. The profile provides information with regard to how the medication should be administered and personal requirements are taken into consideration. The Medication Administration Records (MAR) that were checked had no errors or omissions noted. The ‘homely remedies’ policy and information was seen to be very good with authorisation for use signed by the local GP. However, one point of concern was raised with regard to the possible contraindications of one homely remedy and a service user’s regular prescription medication and the manager took steps to ensure this was withdrawn immediately pending further advice and confirmation from the GP. It was noted that, since the last inspection, one person’s healthcare needs had increased quite considerably and were changing constantly. However, there was evidence to show that these needs continued to be met on a daily basis and the person concerned was observed being treated respectfully and sensitively and continued to have involvement and input at home from family and healthcare professionals. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this outcome area is good. Service users feel their views are listened to and acted on and they are protected from abuse, neglect and self harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure and record keeping was seen to be robust. ‘Tenant meetings’ take place on a regular basis and notes from these meetings were seen, including action taken if necessary on any issues raised, which confirmed that people’s views are taken seriously. Six out of the seven relatives’ questionnaires returned confirmed that they knew how to make a complaint and five out of the six service users’ surveys returned said they knew who to tell if they were unhappy. Financial records were looked at for some of the people living at The Oaks/Woodcroft and a robust system was seen to be in place. Each service user has a bank account and an audit of three people’s cash was found to be correct. Discussions with staff members and training records confirmed that all staff have received training in, and understand, abuse and the protection of vulnerable adults. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is good. Service users live in a homely, comfortable and safe environment, which is clean and hygienic. Service users bedrooms, toilets and bathrooms are individual and private and shared spaces complement their individual rooms. Specialist equipment is available and provided if required, to maximise independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The bungalows at The Oaks/Woodcroft were found to be clean, hygienic and pleasantly decorated throughout. Both had a very comfortable and homely atmosphere. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 17 One person was happy to show me round the Woodcroft bungalow and appeared to be very happy and proud of his room, which looked very comfortable and personal. Service users were seen choosing to use the various communal areas and appeared very relaxed and content in them. One person was observed choosing to have a cup of tea and sit quietly in the well-equipped sensory room, while another was seen assisting with dinner preparations in one of the kitchens. The toilets and bathrooms were seen to offer sufficient privacy for people using them. The manager confirmed plans for the refurbishment of the kitchens and the redecoration of some toilets and bathrooms this year. Various specialist equipment was observed throughout the two bungalows. The gardens were seen to provide a safe, peaceful and relaxing environment for service users and their enjoyment was noted with particular features such as watching the birds using the tables and feeders and use of the garden swing. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good. Staff have clear roles and responsibilities, are well trained, competent and appropriately qualified. The home has robust recruitment policies and procedures. Staff are well supported and supervised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In-depth discussions were held with two staff members and both said they felt the team worked very well together. They also spoke very highly with regard to the support and training received from the home’s management team and the organisation as a whole. Training records were looked at and evidence was seen of courses attended such as first aid, fire safety, health & safety, COSHH, food hygiene, infection
The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 19 control, adult abuse & POVA, moving & handling, equal opportunities and nonviolent crisis intervention. The personnel files that were looked at contained all the relevant records such as application form, contract, confirmation of identification and clear, enhanced Criminal Records Bureau (CRB) disclosures, therefore confirming that the home has robust recruitment procedures. Evidence was also seen to show that staff received one-to-one support and supervision on a regular basis. Both staff members spoken to also confirmed this fact. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41 & 42 Quality in this outcome area is good. The Oaks/Woodcroft is a well run home and the service users benefit from the ethos, leadership and management approach. Service users’ views underpin the self-monitoring, review and development of the home. Service users’ rights and best interests are safeguarded by the home’s policies, procedures and record keeping. The health, safety and welfare of service users are promoted and protected. This judgement has been made using available evidence including a visit to this service. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager of The Oaks/Woodcroft has worked there for eleven years and has been managing the service since 2002. She achieved her NVQ4 in care in 2005 and the Registered Manager’s Award in 2005. The deputy manager is also currently undertaking his NVQ4 in care. A copy of a three-year development plan (2007-2009) was seen and results from various audits were noted as having scored well. The audits covered areas such as health & safety, general overview, medication and monthly provider visits. Action plans had been completed following the results of each audit. The Oaks/Woodcroft has a very person-centred approach with regard to their Quality Assurance process and information was seen to have been gathered from internal audits, external audits, critical events records, client committees, person centred planning, customer complaints and satisfaction surveys. This provided very good evidence that the health, safety and welfare of the service users are promoted and protected and that their views play a major role in the self-monitoring, review and development of the home. Policies and procedures were looked at and found to be up to date and in good order. Health and safety is promoted within the home and records looked at confirmed that fire alarm and safety tests are carried out on a regular basis. Cleaning materials and hazardous chemicals were seen to be stored appropriately in a locked cupboard and staff training in areas relating to health and safety was seen to be up to date. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 X The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations It is recommended that further advice and confirmation from the GP is sought with regard to the possible contraindications of one particular homely remedy and some service user’s regular prescription medication. The Oaks / Woodcroft DS0000027492.V339640.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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
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