Inspection on 20/07/05 for The Woodlands

This inspection was carried out on 20th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Woodlands 15/12/08

The Woodlands 15/12/06

The Woodlands 08/02/06

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 Announced 20 July 2005 9:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Woodlands Address 20 Woodlands Avenue Wolstanton Newcastle-under Lyme Staffordshire ST5 8AZ 01782 622089 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Acorn Care Ltd Joanne Woolliscroft CRH 7 Category(ies) of LD-7 registration, with number of places The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26 January 2005 Brief Description of the Service: The Woodlands was registerd and opened in February 2001 to provide accommodation for up to 7 peopole who have a learning disability. The home provides care for people with a mild to moderate learning disability and who have challenging behaviours. The home is a large detached Victorian building in a desirable residential area of Wolstanton providing easy access to the village and also Newcaslte Town Centre, there is good public transport access. Accommodation is on 4 floors (only 2 used by residents). There is a baswement area with laundry, kitchen and storage areas. The ground floor has a large lounge and separate dinng area, training kitchenette 2 bedrooms and toilet. On the first floor there are 5 bedrooms, bathroom and shower and toilet. The top floor provides office and staff accommodation. All bedrooms are for single use, 4 have en-suite facilities three with baths. There is small garden to the front of the property and large garden area and patio ot 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 E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There were five people in residence and 2 vacancies at the time of this announced inspection. Information was received from all residents in written feedback to the Commission. All residents were spoken to during the inspection. A preinspection questionnaire completed by the home provided some detailed information. Staff were seen and spoken to. A placement officer provided feedback to the Commission. Residents spoken to and written feedback received indicated a general level of satisfaction with the care and services provided by the home. Some residents present difficult behaviours which are well managed by staff. It was pleasing to see that restraint had not been used since the last inspection. De-escalation techniques were working adequately. Two members of staff are now approved trainers in restraint. Plans to upgrade ground floor bathing facilities have been temporarily delayed but still planned. Plans for the garage to be used for recreational purposes mentioned at the time of the last inspection are still in the process of consideration. There is a positive garden project established in conjunction with residents who are working on the project. There has been redecoration of most communal areas and replacement of carpet in the main reception area would further enhance the appearance. Standards relating to care and daily living were found to be met. Good engagement between staff and residents was observed. Some action is required in relation to documentation and aspects of the environment. The home provides a good standard of care supported by committed and trained staff. There is positive working with other agencies. What the service does well: Individual needs are well assessed, well documented and met with a range of in-house and external services. Staff provide a relaxed environment, demands of residents are dealt with coolly and sensitively. Programmes of activity including external access to community facilities are provided on an individual basis. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 6 A resident presenting physical and psychological difficulties is being dealt with by understanding and reassurance. The involvement of external professionals sought and plans in place for joint working. 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 Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 - 5 Standards relating to choice of home were found to be met. There are well managed introductions to the home prior to admission. EVIDENCE: There is a statement of purpose, a copy of which has been given to all residents and also a copy available in the reception area for visitors. The home also produces a Clients Handbook (service users guide), clearly written and given to all new residents outlining what to expect of life in the home. All admissions are through the Care Management Assessment process and required documentation completed prior to admission. This usually relates to CPA arrangements and proposals for aftercare. There have been no new admissions to the home since the last inspection. The statement of purpose states the aims of the home and needs which can be met. A range of external health care an other professionals are involved with residents to ensure specialist needs are met. There are also specialist services offered from within the Acorn Care complex at Cheadle. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 9 There is a good programme of staff training to ensure staff have the knowledge, skills and experience to meet assessed need. Prospective residents are always invited to visit and spend time in the home prior to admission. All previous admissions have followed this course with overnight stays also prior to admission. All residents are funded by sponsoring local authorities who provide a written contract covering all areas in 5.2 of this standard. Contracts are signed by residents who retain a copy. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 - 10 Care plans provide a good standard of information required to meet needs Restrictions upon activity are discussed, agreed and recorded. Residents meeting should be arranged on a regular basis (monthly). Individual needs and choices are generally met. EVIDENCE: Service user plans are developed from assessments and CPA programmes which apply in the majority of cases and are reviewed on at least a 6 monthly basis. A resident presenting current behavioural difficulties is being seen regularly by Consultant Psychiatrist and other health and relevant professionals, the outcome being a continuous process of assessment and review. Care plans sampled indicated good standards of recording and address all aspects of resident’s lives. Daily notes record and summarise the daily progress of residents. All have allocated key workers. Where concerns dictate review of progress specific recording is in place to map progress e.g. behaviour, continence etc. There are written 24 hour plans of care for The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 11 residents, summary of medication with listed potential side-effects, daily records and weekly plan of activities. A new care planning format is currently being piloted prior to introduction. This outlines the required outcomes and will measure daily progress against those objectives. Residents will be involved in daily summary of information providing greater involvement and awareness for them. Residents will express a view about daily care which will be recorded. Care plans are not held by residents as suggested in standard 6.7. the home may wish to review this possibility. Most residents now sign care plans this will be extended to all. Residents are always involved in CPA meetings Residents meetings have been regularly held in the past on a monthly basis but there have only been 2 meetings this year and staff need to take the initiative to again promote regular resident meetings which is important ensuring they are involved in making decisions about daily life in the home and also a means of providing feedback regarding the service. Residents are not currently involved in staff meetings or selection and not represented upon management structures. Risk assessments are in place relating to resident activity. Where there are restrictions upon lifestyle they are risk assessed, known to and agreed with residents, recorded in CPA documents/care plans and explained in detail to residents e.g. going out unescorted, sexuality, self harm etc. Confidentiality is understood and respected. There is a policy relating to this and also data protection. Records are in the secure area of the office on the second floor. Residents do not have access to this area but are aware the information is recorded and available to them if they wish. Requests must be made for access to information, residents do not hold care planning or other information. They are reported to be consulted about sharing information with families and others. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 - 17 There was evidence of providing individual experiences to promote independence and personal development and to access facilities outside the home, limited only by risk assessed and defined restrictions. Daily routines are resident centred. The home is seeking to extend these opportunities further as resident and demand changes. EVIDENCE: Some residents are able to access college course. One currently just completed 1 year course in mechanics up to 4 days per week and will commence second year study in September. Those not able to access college courses are provided with individual support on a daily basis to achieve levels of competency in literacy and numeracy. There is a daily individual activities programme for each resident and a reward system to encourage participation. Leisure and recreational activities are provided by accessing community activities. There is an accent upon accessing non-disability related groups and activities along the lines of normalisation. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 13 All residents require staff escort outside the home at this time. One resident has been on a trust programme and involved with a voluntary group in providing experience of pre-employment opportunities. Most residents are involved in a community reclamation project run by the National Trust/Local Authority. This is ongoing and tailored to suit the needs of residents at specific times. All residents are escorted in the main outside the home on a 1:1 basis, although some activities may be small group e.g. conservation activities, excursions etc. Sometimes behavioural needs may limit the activities of some residents but these are discussed, documented and positive ways forward sought. Social inclusion is the philosophy of the home and pursued very positively. Services and facilities always accessed outside the home. Family and friends are encouraged to visit, one resident goes out with family 3-4 days each week, regular visiting is encouraged and there are positive links by telephone between relatives and residents and staff. Holidays are not provided for residents although this has been recommended for consideration by the home as recommended in standard 14.4. There are clear implications for staffing and finance but the potential benefits could be considerable for residents and staff indicated agreement with the concept. Daily routines promote individual rights and choices and the need for independence and freedom. Any restrictions are discussed, agreed and recorded. Residents spoken to seemed happy with their lifestyles at The Woodlands. This was reflected in feedback forms returned to the Commission. One resident who probably spoke for the majority stated he would prefer to be at home but that staff provided good support and care. Bedrooms are accessed throughout the day from choice and residents have keys to ensure privacy. Staff requested access to bedrooms before entering and there are privacy locks on bedroom doors to ensure privacy at required times. There is a central dining area where residents and staff eat together. The weekly menu is discussed and decided on Sunday, residents then visit supermarkets with staff to purchase food. Mealtimes are flexible to suit activities and needs, generally a hot meal cooked in the evenings by staff. There is a kitchenette adjoining the dining area used by residents to prepare food, snacks, drinks and wash dishes etc competencies are risk assessed and most residents enjoy the activity. It provides a basis for the promotion of The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 14 independent living and social skills. Residents are not allowed into the kitchen area on the lower ground floor in the interests of safety where staff prepare the hot evening meal. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18-20 Standards relating to Personal and Health Care support were found to be met. There is a high level of understanding and good recording of the personal and health care needs of residents. EVIDENCE: Nursing care is not provided in this home, the services of the District Nursing used and adequate as required. All residents have a mild to moderate learning disability, one has a physical disability also and some have additional mental health needs. A range of services both hospital and community based are therefore required to meet the physical and psychological needs of residents. Discussion, observations and inspection of care plans indicated a wide range of services were made available to residents. Apart from the usual primary health care services specialist services from Consultant Psychiatrist, behavioural therapists/advisors, CPN’s, and the homes Cognitive Therapist were accessed. On the day of inspection the Cognitive Therapist had the usual weekly meeting with 3 residents providing therapeutic support in social and psychosexual The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 16 awareness, the objective being to achieve greater self awareness and improvement in behaviour and social functioning. Physical health care needs are well documented. A resident with complex physical needs and extreme oedema has been referred over a long period of time to various specialists, initiated by the home and pursued very consistently. Staff are directly involved in his treatment and limited only by the resident’s unwillingness to pursue medical advice. A resident presenting difficult behaviour was being seen almost weekly by Consultant Psychiatrist with medication reviews and changes being tried to attempt to find the correct balance of physical and mental health care. Personal support is required minimally in the home at this time. Several residents require oversight in matters of personal hygiene and this is provided sensitively. The medication system and records were inspected and found to be accurate and safe. There was good recording of medication administered, only one signature missing from MAR charts. All medication returned to the pharmacy is listed, signed by staff and countersigned by the pharmacy. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Standards relating to concerns and complaints were found to be met. Standards relating to the protection of residents were not met. Many staff have not seen/signed the policy/procedure relating to the definitions of abuse and instructions for reporting it. EVIDENCE: The complaints procedure is on display in the home for residents and visitors. There is also a copy in each bedroom for the use of residents. The procedure is provided in 2 formats, written and pictorial to ensure all residents are aware of the procedures. One complaint has been received by the home and swiftly responded to. It related to communication between the home and a relative. No complaints have been received by the Commission since the last inspection. There is a policy/procedure relating to the broad definitions of abuse and procedures to be followed in the event of suspected or actual abuse. This document is signed by staff when they have seen it, but it appeared that less than 50 of staff had signed the document. It is vital that all staff are aware of and understand the procedures for reporting abuse and it is a requirement of this report that staff are provided with information/training in relation to abuse to ensure the protection of residents. It is suggested that all existing and all new staff are given a copy of the procedure and sign to say they have seen and understood the procedures. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 18 Physical and verbal aggression by residents is understood and dealt with by staff. An offending behaviour course was recently provided for staff to increase awareness in this particular area. Matters relating to residents finances were not inspected on this visit. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 - 30 The environment is generally to a good standard. Planned improvements to the ground floor bathing facilities will assist residents with some physical disabilities. Most communal areas have been recently redecorated. Replacement of the carpet in the reception area would improve the overall appearance of this key area. EVIDENCE: The home was opened 4 years ago and provides a good standard environment. There is an ongoing programme of improvement and redecoration which has recently been interrupted by work being completed on another complex owned by Acorn Care. There were plans to create convert the 2 ensuite rooms of the 2 ground floor bedrooms into bathrooms, to accommodate the physical needs of those residents. These plans will be carried out but have been delayed for the reasons stated above. This is particularly important for the residents who have difficulty accessing the first floor bathroom. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 20 Furniture, fittings and equipment are generally to a good standard and are along domestic lines to mirror a domestic environment. The lounge area is large, pleasant, comfortable and well furnished, sometimes it has to be used for meetings occasionally restricting resident use but there are plans to develop an area on the top floor for those purposes allowing continuous use of the lounge area. A new digibox has been provided for the residents wide-screen TV which they enjoy. Many remarked the quality of the TV signal had deteriorated recently, in bedrooms too. Apparently an arial contractor is being contacted. A placement officer in feedback to the Commission had sated that the downstairs bathroom and general décor needs attention. The bathroom is earmarked for upgrading as stated above. The inspector feels that the standard of decoration and décor on the ground floor is good but that the state of the carpet in the reception area detracts from the decoration and should be replaced. At the time of the last inspection remedial action was required to combat the damp in the lower ground floor kitchen food storage area. This has been done with new membrane installed and re-plastering. The skirting board now needs to be refitted and sealed to complete the task. The kitchen area was clean, a cleaning schedule in place. Fridge/freezer temperatures recorded regularly but there was no probing of food. Bedrooms are generally well appointed and allow space for residents collection of memorabilia and all rooms have the usual TV/CD/DVD/Video/music facilities. The home is a large Victorian detached building with retains some original character. There is a developed garden/patio to the rear but a large area is being further developed at the bottom of the garden, this is called the garden project and has been agreed and planned with residents. The objective is to provide a basketball area, sitting area and facilities for a BarBQ in that area. The work is progressing, residents carrying out their planned ideas. The building is not identifiable in this residential area, as a home. Residents expressed concerns at the last inspection about lack of privacy whilst in their bedrooms, there had been instances of other residents arriving uninvited. A recommendation was made to review the locks on bedroom doors. There appears to have been some misunderstanding about this. On this inspection all bedroom doors were found to be lockable with a key when residents were not using them and there was a flip lock on the inside of the doors which resident could use whilst in their bedrooms. These could be easily opened by staff in an emergency. The locks therefore currently fitted to The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 21 bedroom doors are satisfactory and allow required privacy from choice with easy access in an emergency. Standards of hygiene in the home were good and infection control notices and appropriate hand-washing facilities strategically located. The laundry area provided adequate space and facilities for its p urpose. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 - 36 Staffing numbers are adequate. There is a good staff training programme. Recruitment procedures are adequate but induction procedures should be reviewed and strengthened. There is good staff engagement with residents who benefit from positive staff support. EVIDENCE: All staff have job descriptions with clearly defined roles. Policies and procedures are available in the staff room for the reference of all staff. Staff sign to indicate they have read and understand particular policies, but there were many omissions indicating that staff had not read and were aware of the policies/procedures in place. This needs to be addressed. Two new staff have commenced duties since the last report. Files were inspected and all required documents, references etc. obtained and in place. There was evidence of good recruitment procedures. Induction documents relating to new staff were seen. Some had not been signed by staff or dated. There was no evidence of the induction procedures content and extent of work done by staff and trainer. It is recommended that The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 23 the induction procedure be reviewed to provide evidence of the level of training and to ensure it is to NTO standards. 17 care staff are employed. 9 have obtained NVQ2 or above and further 7 studying NVQ3. The home therefore meets the required 50 of NVQ trained staff required by 2005. There has been some staff training in Fire Awareness, moving & handling, first aid and medication training since the last inspection. A course has also been provided for staff on Offending Behaviour. Further training is planned in most of those areas and in team building during the year. Two staff have completed a trainers course in control and restraint and will therefore provide training for all staff in this important area for this home. Staffing hours remain virtually the same as required at April 2002. The staffing level is basically 3:4:2 and been sustained presently at around 510 hours per week (additionally some hours provided by Manager). There are presently 5 residents and 2 vacancies, the staffing level when full is 550 hours per week, this is generally maintained as occupancy levels reduce but slightly less at present due to vacancy unfilled, holidays etc. The current staffing level is adequate for the perceived dependency levels of the resident group. Staff supervision is in place as required (records not seen on this visit). The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 - 42 There are indications of positive leadership and management. Some areas of Quality Assurance are patchy and could be improved. Additional policy procedure is required for Food Safety and all policies/procedures should be reviewed with proof that staff have read and understood them. Record keeping in relation to resident care was found to be to a good professional standard. Some aspects of safe working practices require action. Financial viability could not be assessed as documentation was not available. The overall conduct and management of the home was satisfactory attention required only to the points above. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 25 EVIDENCE: The Registered Manager was approved by the Commission in November 2004. She has the required experience to run the home. She enrolled on a course in January to complete the NVQ4 and Registered Managers Award and hopefully will complete the course by January 2006. This will meet the required standard for Registered Managers. The Manager has established a positive relationship with residents and staff and there have been several new staff appointments subsequently. Regular staff meetings are held on a monthly basis (records seen). There appears an open and positive atmosphere in the home between all staff and residents. Other professionals are welcomed into the home and there are positive working relationships between staff and all professionals. There is a clear and concise complaint procedure in place to ensure residents understand the process for making complaints. Pictorial questionnaires are available to assess resident satisfaction with care but not recently used. The views of relatives and other stakeholders are not presently sought. Acorn Care Ltd have a Development Manager with responsibility for audit of care. The home and proprietors have a good record of compliance with requirements made by the Commission following inspections. Some policies and procedures have been added or reviewed but the majority have not and the Manager should ensure regular review. Standard 40.6. requires “all policies, procedures, codes of practice and records to be signed by the Registered Manager, dated, monitored, reviewed and amended”. There is no policy/procedure relating to food safety and nutrition and this should be provided. A policy relating to gifts to staff has been provided since the last inspection. Some matters relating to Safe Working Practices require action they are: A policy relating to Food Safety & Nutrition must be provided. Annual Fire training must be provided for all staff. The Fire alarm system must be checked weekly there were several gaps in records seen. It is recommended that an additional/alternative lock is provided on the entrance to the COSHH storage area – presently there is a “star” key used which is not unique and could possibly be opened by alternative means. There is bleach stored and residents with history of self-harm - alternative locking would ensure absolute safety. Maintenance records were spot checked and equipments serviced as required. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 26 First aid training has ensured one trained person on duty at all times. Risk assessments relating to resident activity, the building and fire are satisfactory. All incidents required to be notified under Regulation 37 have been received by the Commission. The home is asked to review the induction training programme to ensure required standards are achieved. In relation to the financial viability of the home, proprietors were not seen on this visit and as stated in the last inspection it is necessary for proprietors to forward documents to the Commission indicating the financial viability of the home. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Woodlands Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 2 x E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 28 no 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 42 23 Regulation 16(2)(j) 13(6) Requirement Provide policy on food safety & nutrition and ensure checks are carried out with food probe. The Registered person shall make arrangements by training staff or other measures to prevent service users being harmed or suffering abuse Provide annual fire training for all staff The fire alarm system must be checked and recorded weekly Timescale for action 31.8.05 31.8.05 3. 4. 42 42 23(4) 23(4) 31.8.05 Ongoing 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 24 42 35 Good Practice Recommendations The replacement of the reception area carpet is recommended. Consider additional/alternative lock on COSHH cupboard to ensure safety. Review induction procedures and documentation to provide evidence of induction to NTO standards. The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Woodlands E51-E09 S5028 Woodlands V235379 200705 Stage 4.doc Version 1.40 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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