Inspection on 15/12/06 for The Woodlands

This inspection was carried out on 15th December 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Woodlands 15/12/08

The Woodlands 08/02/06

The Woodlands 20/07/05

The Woodlands 26/01/05

The Woodlands 19/10/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Woodlands, 20 Woodlands Avenue Wolstanton Newcastle Under Lyme Staffordshire ST5 8AZ Lead Inspector Peter Dawson Key Unannounced Inspection 15 December 2006 09:00 The Woodlands, DS0000005028.V320640.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 Woodlands, DS0000005028.V320640.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 Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Woodlands, Address 20 Woodlands Avenue Wolstanton Newcastle Under Lyme Staffordshire ST5 8AZ 01782 622089 01782 715412 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) Acorn Care Limited Joanne Woolliscroft Care Home 7 Category(ies) of Learning disability (7) registration, with number of places The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8 February 2006 Brief Description of the Service: The Woodlands was registered and opened in February 2001 to provide accommodation for up to seven people who have a learning disability. The home provides care for people with a mild to moderate learning disability and may have challenging behaviours or mental health needs. The home is a large detached Victorian building in a desirable residential area of Wolstanton providing easy access to the village and also Newcastle Town Centre, there is good public transport access. Accommodation is on four floors (only two used by residents). There is a basement area with laundry, kitchen and storage areas. The ground floor has a large lounge and separate dining area, training kitchenette and 2 en-suite bedrooms. On the first floor there are five bedrooms, bathroom and shower and toilet. The top floor provides office and staff accommodation. All bedrooms are for single use, six have en-suite facilities three with baths. There is small garden to the front of the property and large garden area and patio to the rear. Staffing rosters support occupational needs throughout the day. A range of specialist services are accessed in the community providing necessary support to residents. Aims are to promote independence and empowerment wherever possible, limited only by risk assessed and well defined limitations of freedom. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by one inspector on one day from 9am – 3pm. A pre-inspection questionnaire was completed by the service and provides a basis of information in this report. Feedback directly to the Commission was received from 5 residents, 2 relatives and a Care Manager. All residents were seen during the inspection and spoken to separately and together. Several showed the inspector their bedrooms providing the opportunity for private discussions. All residents spoke highly about the care they received at The Woodlands. Three have been admitted in the past 10 months and all stated that they had been appropriately introduced prior to admission and helped to settle by staff. They were all happy with the activities provided for them, in particular the external opportunities for work-experience. A resident admitted 4 months previously was eagerly awaiting a college and work experience placement He was hopeful of swift arrangements being made but staff felt that this gave him time to orientate again in the community. All residents in written feedback expressed satisfaction with the service provision. One said he “ enjoyed going home 4 times per week” Another said “I follow a daily programme and have choice in some things”. A Lead Social Worker in Forensic Services stated “ I have been impressed with the work on the rehabilitation programme give to my client. The flexibility to adjust the programme to meet his needs seems paramount. I would not hesitate to recommend this placement to other professionals/service users”. An Acting Manager has been running the home for the past 6 months in the absence of the Registered Manager on maternity leave. She has managed the home well, has made some progress in areas of care planning, recording and reviews and has considerable knowledge of the needs of residents. What the service does well: The home provides a good service for 7 people with a learning disability and mental health needs. Some behaviours are challenging but there has been no restraint in the home over the past two years. There have been staff changes and admissions of new residents since the last inspection. New staff spoken to were positive about their commitment to resident care. New residents said that they were happy at The Woodlands, all were previously in long-term hospital care. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 6 Residents recently admitted said that they had made several visits to the home prior to admission allowing them to make an informed decision about the suitability of the home. Permanency of placement was subsequently confirmed after the initial settling in period. There are individual activity programmes for residents. Where possible external resources such as college courses and work placements are accessed. There is ongoing contact with health care professionals including GP, Consultant Psychiatrists and other learning disability professionals. Additionally the home has a central resource for specialist inputs from the Acorn Care unit at Cheadle (same ownership) which is registered as a private hospital. What has improved since the last inspection? What they could do better: Staff recruitment procedures should be improved to protect residents. Further staff training in Vulnerable Adults procedures are needed. The Statement of purpose should be updated. The updating of care plans should continue. Changes of ownership must be notified to CSCI and regular monthly visits made by the Responsible Individual. Fire drills should contain names of staff and residents involved in drills. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 7 Records of complaint investigations must be kept in the home for inspection. A health care record for each resident should be established. Repainting of external windows is needed. 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 Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 - 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose requires updating. Pre-admission assessments and introductions to the home were in keeping with good practice. EVIDENCE: There is a Statement of Purpose and Residents Handbook (Service Users Guide). Copies are available in the home for visitors and each resident has a copy in their bedroom. The Statement of Purpose requires updating to include the changes of ownership and Responsibility Individual appointed to visit the home on a monthly basis. Two new people have been admitted to the home since the last inspection. Both were spoken with and said that they had settled well. They confirmed that introductions to the home had been made with day and overnight stays prior to actual admission. There had been a review of placement (seen) in The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 10 relation to each person. A progress report had been compiled in relation to one still being monitored by Care Management specialist. Preadmission assessments had been carried out appropriately by the home. Contracts were not seen on this visit The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6 - 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Greater resident participation in care planning continues. This can be further extended. There were many positive aspects of the care planning system seen. EVIDENCE: A new care planning format was in the stages of introduction at the time of the last inspection, there were some staff concerns about the new format and it was recommended at that staff training was provided. This has not taken place, staff have continued with the introduction of the plans with some assistance from senior staff. Progress has been made and continues. Risk assessments were seen and were good, clearly identifying aspects of risk in daily living and steps taken to reduce risks. Risk assessments included use of alcohol, self, harm, arson etc. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 12 More extensive ownership of care plans was recommended in the last report – plans were located on the second floor of the building to which residents did not have access. There appears to have been some confusion about this and a duplicate copy of the plans is now kept in the small office area created on the ground floor of the building. This provides duplication of work and some incompatibility between the two. It is quite acceptable to CSCI for a single care plan to be available on the ground floor, readily available for residents. The home may wish to move towards care plans being located in residents bedrooms. There is a 28 day plan of care for each resident with a summary of salient points from the care plan. There is a daily evaluation of those plans and a monthly review of progress by the key-worker and resident. It is recommended that resident and key-worker sign those reviews. These are positive moves towards resident involvement and ownership of care plans. There were many good aspects of care planning information seen. The Acting Manager has re-introduced residents meetings – a positive step in allowing residents an opportunity to express their views about the service. Residents meetings in this home in the past have been good, staff ensuring that all residents have an input into the discussions. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11 - 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents personal development, occupation and social inclusion was evidenced. Family contracts are promoted. EVIDENCE: Residents attend college courses at local colleges and are involved in work experience-type placements. Three residents are involved in placements with the Landau Trust, which involves course work then a work experience placement. They are presently on work placements at Halfords, Sainsbury’s and B & Q. All proud of the fact that they have jobs. The person at Sainsbury’s spoke enthusiastically about his responsibility for collection and storage of shopping trolleys and showed his uniform and name-badge with The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 14 pride. One had a previous placement at Alton Towers which ceased at the season end but now had alternative placement. A recently admitted resident is awaiting college placement and similar work placement. The Landau placements replace the former reclamation work residents were involved in. That was good but the change is more work-like for these residents. A range of courses have also been provided at Willfield and Burslem colleges. All activities are community based where possible but those not on external activities or not attending college/work placements on particular days are involved in daily activities in the home centred around numeracy, literacy, art/craft activity or simply 1:1 engagement for which they are paid a weekly “wage”. Adequate transport is readily available in the form of the homes people carrier and authorised use of staff cars. In the past virtually all residents have been escorted by staff outside the home. This has changed positively with several going out together or individually. One resident with some anxiety about going out alone, walks to the local shops already making some progress. Risk assessments are in place relating to going out escorted, road safety etc. Personal development promoted with reduced and acceptable risks. All residents have responsibility for cleaning their bedrooms, laundry and some food preparation. There is a training kitchen where residents prepare breakfast, drinks, snacks etc. One person, very interested in catering, prepares dishes for the main meal of the day on occasions. Since the last inspection the garden area has been redeveloped. A grassed area created and retaining wall and Bar B Q built. Residents have enjoyed the project and showed it with pride. They had recent Halloween Bar B Q there. Family contacts are promoted. One resident goes home on 4 days each week, others have day or overnight stays where possible. At Christmas four residents are going to family for overnight stays of up to one week. There are only 3 residents remaining but plans are in hand to provide some family contact and Christmas festivities. The home was very well and interestingly decorated for Christmas with several large Xmas trees and other Xmas decorations throughout the home. Residents have been involved in this and was a subject for discussion. Food provision is good. This was confirmed by residents and menus demonstrated a varied diet with residents choices. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 – 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A broad range of health care services are accessed through GP and specialist services. Medication is handled safely. EVIDENCE: Nursing care is not required/provided in this home. The District Nursing Service is used where required but there is no involvement at this time. None of the current resident group have a physical disability and personal care needs are minimal with oversight only required in relation to personal hygiene etc. All residents have a mild to moderated learning disability. A range of service both hospital and community based are provided with primary health care needs met by local GP practice/health centre and specialist services provided The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 16 by the Learning Disability Directorate. The Acorn Group has specialist advisors, cognitive therapists, who augment/support those serviced. Most resident have allocated consultant Psychiatrist who reviews residents regularly on an as required basis or with other professionals as part of the CPA arrangements. Under these arrangements residents have allocated Care Co-ordinators/Key Workers and allocated CPN’s provided if required. Health care records include regular weighing and recording of past and future appointments with health care professionals. Information is in different places/format and the home should establish for each resident a Health Care Record Sheet – recording diagnosed conditions, a chronological list of interventions by health care professionals with outcomes and a list of arranged appointments with specialists. This is particularly important in situations of urgency or admission to hospital. The home provides a service to people with a learning disability who may challenge the service. It is pleasing to report that no incidents of restraint have been necessary in the home over the past 2 years. Incidents are swiftly diffused by staff who are trained in diversionary tactics as well as physical restraint. The medication system is provided by Boots Chemists in MDS (blister-pack) form. A good service is reported from the pharmacy. There is no selfmedication in the home at this time. Anti-psychotic medication is in use in relation to some residents but reviewed regularly by Consultant Psychiatrists. All records relating to medication administration were accurate and completed as required to ensure a safe system is in place. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure in place. Records of complaints must be kept in the home for inspection. Some staff required training in Vulnerable Adults procedures. EVIDENCE: A copy of the complaints procedure is available in the home for visitors and all residents have a copy of the pictorial complaints procedure in their bedroom. A resident made a complaint of mal-treatment by a member of staff in May this year. He made a written complaint himself to the main office of the providers. This was notified to the Commission and the outcome that there was no evidence of mal-treatment was also notified to the Commission. It was not possible on this visit to see the investigation report concerning the incident. The records were at the Groups main office. It is important that the investigation and outcomes of complaints are kept in the home for inspection. A copy of this investigation should be forwarded to the Commission. There has been training in the protection of vulnerable adults in the past, but several staff have not received this training. This should be provided. This is particularly important for new staff. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 - 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well established environment which has been well maintained and improved over recent years. The presentation of the home is good. EVIDENCE: The home was opened 6 years ago and has provided a good standard environment with ongoing improvements. There have been further improvements since the last inspection. En-suite facilities have been added to the 2 ground floor bedrooms, both with showers. They have been well planned and constructed providing excellent facilities. The under-stairs storage area has been converted into a small office area for care staff where residents records can be sited rather than on the 2nd floor of the building. It was recommended in the last report that the approval of the Fire Officer was sought for the internal re-arrangement of the premises. It The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 19 appears that this has not been done and should be discussed with the Fire Officer as soon as possible. New dining room furniture has been purchased, residents involved and also in the wood-staining of the furniture. The tables are smaller, rather than the large rectangular tables previously and present a more pleasing and homely appearance to the dining area, which doubles as an activity room. There has been redecoration also. The furniture in the large main lounge has been replaced, with comfortable and pleasing large settees/chairs. The presentation of this area is also much improved providing a homely attractive setting. Bedrooms were sampled escorted by residents, all were well personalised and adequately furnished. The curtain rail in one bedroom required replacement. The garden area has been improved with grassed area, walls built and also brick Bar B Q. Residents have enjoyed planning and constructing this project. The garden area is now attractive, functional and extended. The only area of the environment seemingly needing maintenance is the painting of the wooden windows to the front of the home. Paint has perished leaving bare wood in many places. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 - 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff training is satisfactory. Some improvement required in the area of staff recruitment. EVIDENCE: The home maintains the required staffing level of around 550 hours per week, although there have been minor variations with recent reduced occupancy. This has been maintained following full occupancy. In fact there are plans to increase the staffing hours. There are generally 3 and sometimes 4 staff on duty throughout the waking day staffing shift which is from 7.30 a.m. to 10 pm. Recruitment is current for additional staff so that 4 people will be available throughout the day. This will fully support the homes good efforts to engage residents in individual activities and provide necessary transport and support. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 21 The staffing levels are adequate for the dependency levels of the current residents group. The staffing records of 2 recently appointed Support Workers were inspected. There were concerns about aspects of recruitment. Reference reply forms are used and not addressed when posted, it is not possible to identify who returns them. The names of referees on the application form did not match those on the completed reference forms. It was not clear whether a reference had been obtained from the last employer. There was no POVA or CRB in place for one member of staff, only a letter from CRB months after commencement of employment stating that a “ reply from local police was awaited”. There was not further correspondence. The written and verbally stated, previous employment of one member of staff did not equate. These matters must be pursued and rectified. Staff training is good. Training required in the Protection of vulnerable adults. Over 50 of care staff are trained to NVQ level and several staff also studying to this level. Good engagement between residents and staff were observed throughout the inspection. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37 – 38 & 41-43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Change of ownership must be reported to the Commission and Regulation 26 visits and reports provided. Management of the home is good. Safe working practices are generally good. Attention required only to fire drills. EVIDENCE: It became clear during the inspection that the ownership of the home had changed. Details were not known and it is a requirement of this report that details of the change of ownership are notified to the Commission immediately The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 23 as this may affect registration. It was also clear that the nominated Responsible Individual had changed and that regular monthly visits under Regulation 26 had not been carried out and reports therefore not provided to the home. The change of RI must be notified to the Commission and regular monthly visits carried out under regulation 26. The Registered Manager has been on maternity leave during the summer months returning the previous month. The interim arrangements were approved by the Commission – an Acting Manager appointed to run the home during that period. It was clear that she had provided management cover to a high standard and made progress in some areas of work which were needed. She was on duty at the time of this inspection. There was a very relaxed atmosphere in the home good and positive exchanges observed between staff and between staff and residents. Residents finances were not inspected on this visit but there was some discussion with 3 residents with vastly varying weekly allowances available. One resident had the basic personal allowance. His finances are managed by a Social Worker and it is possible that he had further monies available to him. The home will pursue this matter with the social worker in the residents interests. It was unhelpful to the particular resident when comparisons were made amongst residents about the amount of money available for purchasing Christmas presents and availability of cash for social activity etc. Fire records showed that equipment had been tested and serviced at required intervals. It is important that all staff have 3 monthly fire drills and that records show a list of staff and residents involved in drills. This was a requirement of the last report and further requirement of this report. It was reported that residents respond positively and urgently when the fire alarm sounds and proceed to exit the home swiftly. The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 x 3 3 X X 3 2 2 The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 25 N0 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 2 Standard YA1 YA6 Regulation 4(1) Sched 1. 15(1) (2) Requirement The Statement of Purpose must be updated to reflect recent changes of management. Continue to update care plans as current documents of need. Provide staff training/support in this task. Records of complaints must be kept in the home. Provide SCSI with copy of identified complaint. Curtain rail in bedroom identified to be replaced. All staff must be training in adult protection. Staff recruitment policies/procedures must be improved. POVA or CRB always obtained prior to employment 3 monthly fire drills must be carried out, recorded and include names of staff and residents. CSCI to be informed of change of ownership. Responsible Individual notified to CSCI and regular monthly visits carried out and recorded. Timescale for action 31/01/07 28/02/07 3 4 5 6 YA22 YA26 YA23 YA34 22 Sched 4(11) 23(2)(c ) 13(6) 19(1) Sched. 2 23(4) 26 31/01/07 31/12/06 28/02/07 18/12/06 7 8 YA42 YA43 18/12/06 18/12/06 The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 26 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 3 Refer to Standard YA19 Good Practice Recommendations A Health Care Record sheet is recommended for all residents identifying all health care needs and chronological record of health interventions. Repainting of exterior woodwork is needed. Review with Social Worker amount of weekly finance and savings of resident identified and notify resident. YA24 YA40 The Woodlands, DS0000005028.V320640.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 The Woodlands, DS0000005028.V320640.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. Re-publishing this information is in breach of the terms of use of that website. 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