Inspection on 08/02/06 for The Woodlands

This inspection was carried out on 8th February 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 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 15/12/06

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 Unannounced Inspection 8th February 2006 09:00 The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 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.V282800.R01.S.doc Version 5.1 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.V282800.R01.S.doc Version 5.1 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.V282800.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 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 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 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 two bedrooms and toilet. 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, four 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.V282800.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this unannounced inspection there were six people in residence and another person in the introductory stages to the home which would bring the numbers to the approved maximum of seven people. Two new people have been admitted to the home since the last inspection one several months ago the other the previous week. Good pre-admission procedures had been followed with introductions allowing prospective residents to make an informed decision about suitability of the home for them. This was confirmed in discussion with the two residents concerned. All residents were seen and spoken to during the inspection, some invited a tour of their bedrooms. All said they were satisfied with the care provided at The Woodlands and that they were listened to by staff who spoke to them courteously and generally treated them with respect. They were all satisfied with the activities internally and externally that were provided for them and felt able to make comments about the service. All staff on duty were spoken to and made a contribution to the inspection process. Staff dine with residents and the atmosphere at breakfast and lunchtimes were observed to be relaxed with friendly exchanges and discussions between staff and residents. There are plans to add/improve en-suite facilities, including showers to two ground floor bedrooms. The building is generally well maintained and the garden area presently being further developed. What the service does well: Prospective residents make timed introductions to the home allowing them to make a decision about suitability of the home. Permanency of placement is confirmed only after three months in residence, allowing a further period of reflection. There is a good range of activities available to residents with an accent upon community involvement. Although most residents are escorted outside the home, staffing is flexible to accommodate that and transport readily available. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 6 Swift referral is made to external professionals where changes in need are indicated. The home also has a central resource for specialist inputs from the Acorn Care unit at Cheadle. 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, DS0000005028.V282800.R01.S.doc Version 5.1 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 Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 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 the following standard(s): 1-5 Pre-admission procedures have been followed adequately in relation to two recently admitted residents, with good assessments and introductory visits. Appropriate documentation is in place including the Statement of Purpose/Service Users Guide, contact etc. Standards relating to Choice of Home were evidenced to have been met. 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 at The Woodlands. All admissions are through Care Management Assessments processes and the required documentation completed prior to admission. This usually relates to CPA arrangements and proposals for aftercare. In relation to two new admissions since the last report, there was a pre-admission assessment on file and a Care Management Assessment - completed on multi-disciplinary basis as required under the Mental Health Act and discharge arrangements. There was The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 9 a copy of the care plan agreement on file signed by the prospective service users. Pre admission procedures and documentation ensures that good assessments are made and suitability and compatibility with the placement ensured. The statement of purpose outlines the range of health care and other professionals required to make a contribution to the total care concept. There are additional services provided to the home from within the Acorn Care Complex at Cheadle which is in the same ownership. Prospective residents are always invited to visit and spend time in the home prior to admission and this was clearly followed in discussions with the two people recently admitted. Both residents admitted from different venues had spent time, including overnight stays in the home prior to admission allowing them to make an informed decision about the suitability of the placement for them. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 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 the following standard(s): 6 - 10 There was good and comprehensive information available in relation to each resident. Care plans were based upon assessed need. Information is not summarised clearly in care plans, some is dated from previous settings and should be updated/reviewed. The proposed introduction of a new care planning system focusing upon resident involvement is good but staff are not clear about its implementation and training is required to clarify this. Copies of Guardianship orders must always be available in the home as evidence of legal status. EVIDENCE: Care Planning information included and was based upon multi-disciplinary assessments. Most are subject to CPA arrangements and reviewed with Consultant and others involved in care on at a least a six monthly basis. Daily notes summarise and record daily events often with three entries. All have allocated key workers. Documentation relating to 2 recently admitted The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 11 residents was reviewed. There was a 24 hour plan of care in each case, indicating the required and preferred routines from rising to sleeping. There was a medication summary which in one case differed from the current medication – it included a list of anti-psychotic PRN medication prescribed prior to admission that has apparently been discontinued. One person was subject to Guardianship under the Mental Health Act but there was no copy of the order in the home. This is required to validate the legal status of the person – the police have already acted in relation to the Act. Risk assessments were in place but in one instance a review of the risk assessment provided from the previous placement was required. At the time of the last inspection the home were piloting a new care planning format which focussed on outcomes and daily progress with resident involvement. It was proposed that care plans were held by residents. This has been introduced in a piecemeal way, with some residents records being changed in part only. There seemed to be confusion about the system being introduced in total, some areas had been introduced for a newly admitted resident but not other areas. Apparently the system has been fully introduced at another registered service in the Group – but not at The Woodlands. It is recommended that staff training and greater clarification should be provided for all staff in the use of the new care planning system. There were previously regular residents meetings but these have become infrequent. The meetings provided a positive focus in the group situation in allowing them to express their views about all aspects of life in the home. It is strongly recommended that residents meetings are resumed. Information is kept securely in the office area on the top floor of the home to which residents do not have access. Care planning information is contained there. This means that confidentiality is assured but there is no easy access to care planning information by residents. The preferred option in Standard 6.7 for plans to be held by service users does not take place and this was highlighted in the last report. One of the recently admitted residents does have part of the care plan in his possession in his bedroom the others do not and more extensive ownership by residents of care plans should be developed. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 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 the following standard(s): 11 – 17 There are good programmes in place to promoted personal development. All residents have programmes of external activity relevant to their needs and aspirations. Transport and staff time is readily available to service external activity which is imperative to achieving the objectives set. Personal, family and sexual relationships are promoted and supported with examples seen/discussed with residents. Food provision is good with resident involvement in planning, shopping and preparation. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 13 EVIDENCE: Some residents are able to access college courses and are encouraged to do so and supported in attendance. Courses have included life skills, literacy & numeracy, car mechanics etc. Colleges at Willfield, Burslem and Stoke area accessed with leisure emphasis for some residents e.g. aromatherapy, art, jewellery making and art. All residents have an individual programme of daily activity which is agreed with them and forms part of CPA an care planning objectives. There are daily activities based in the home which those unable to access external courses partake with all residents. Activities include literacy and numeracy and the usual table activities. There is an incentive for this with a small daily payment and extra total weekly payment if all sessions completed. All residents generally complete these activities. External activities also include work on a reclamation project run by the National Trust/Local Authority based on development of local natural parkland. This has recently been extended to include another project in North Staffs including the Stoke and Leek areas. Activities increase on the project as spring approaches but many residents are involved and enjoy the project. All residents with the current exception of one are escorted outside the home on a 1:1 basis. Residents spoke with detail about visits to shops, cafes, pubs etc indicating an ongoing programme of external recreational visits. One resident is allowed to go alone to local pub with a strict agreed timetable of reporting and contact (he has mobile phone) with defined action if the agreement is breached – which sometimes happens. Nevertheless this is a positive trust programme agreed with the resident. Holidays are not provided for residents although this has been recommended in the past as recommended in standard 14.4. There are clear benefits for this with this young age group of residents. The development of social, emotional communication and independent living skills are the basis of the homes philosophy, evidenced by activity mentioned above. Additionally there is input from behavioural therapists from the Health Trust and the other specialist unit in the Group. Courses in anger management and offenders therapy group are accessed in this way. A Psychology student in the employ of the home has recently presented training session on Social Skills Therapy to the staff and there have been Team Building sessions for staff also. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 14 Family contacts are promoted where possible visits to the home and external visits with relatives are encouraged. Telephone contact is encouraged as a two way process. Two residents have mobile phones. Residents said that food provision was satisfactory for them. They are involved in routines to prepare breakfast, tea, snacks and drinks. There is a good training kitchen adjoining the dining room where residents take part in rotas for food preparation, washing up etc. On the day of the inspection several residents were enjoying cooking individual pizzas with staff supervision. The kitchen is located on the lower ground floor. Previous requirements made in relation to that environment have been actioned. The EHO recently visited and made some recommendations (report not available at this time). The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 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 the following standard(s): 18 - 21 The health, social and emotional needs of residents were seen to be met. There is a safe system of medication in use in the home. It is recommended that the wishes of all service users in relation to death are known and recorded. EVIDENCE: Nursing care is not required/provided in this home. The District Nursing service is used and is adequate for any physical needs of residents. All residents have a mild to moderate learning disability. A range of services both hospital and community are provided with primary health care needs met by local GP practice/health centre and specialist services provided by the Learning Disability Directorate. The Acorn Care Group has specialist advisors, cognitive therapists, who augment/support those services. All residents 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 all residents have allocated Care CoThe Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 16 coordinators/Key Workers and allocated CPN’s, although the latter reported to be involved only as requested via the Consultant. The home provides a service for people with a learning disability and challenging behaviours and whilst there is the potential for the latter there have been no incidents of restraint used in the home over the past year. Alternative diversionary methods are successful. Two staff are approved trainers in restraint, have trained other staff and had recent update of training themselves. At this time there is no resident with a physical disability. Personal support is required minimally and centres upon staff oversight in relation to matters of personal hygiene. Several are being monitored closely with regular reviews of anti-psychotic medication and anti epileptic medication. Staff work closely with the Consultant Psychiatrist on these issues. The medication system was inspected and found to be satisfactory. All medication is appropriately recorded and signed for when administered by staff and returns to the pharmacy are listed and countersigned by the pharmacy. None of the current resident group is deemed able to self-medicate. In relation to ageing, illness and death the home were advised, following discussions, to sensitively seek the views of residents/relatives in relation to these matters and to record them. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 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 the following standard(s): 22 - 23 The complaints procedure is in place and is satisfactory. All staff have now received training relating to abuse. Standards relating to Concerns, complaints and Protection were found to be met on this visit. EVIDENCE: The complaints procedure is on display in the home for visitors and residents. There is also a copy in each bedroom for the use of residents. The procedure is provided in two formats: written and pictorial to ensure all residents are aware of the procedures. No complaints have been received by the home or by the Commission since the last report. There is a policy/procedure relating to abuse of residents and the procedures to be followed in the event of actual or suspected abuse. At the time of the last inspection it was clear that not all staff were aware of the procedures or indeed had signed the document as proof of their awareness. A requirement made to provide all staff with appropriate training and awareness of the procedures has been actioned. Most staff have accessed an external course relating to Vulnerable Adults and the procedures and all have received a personal copy of the homes procedures. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 - 30 The home presents a warm, comfortable, homely atmosphere and environment along domestic lines. The building is well maintained. The proprietors should submit the proposed internal changes to the building to the Commission and seek the approval of the Fire Officer for the required changes. Bedrooms are well furnished and personalised to which residents have constant access and ownership. Standards of hygiene were high. EVIDENCE: The home was opened over four years ago and provides a good standard environment and is well maintained. The home is a large detached Victorian house in a desirable residential area. It is not identifiable as a home in the community. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 19 There is a large garden area to the rear which is being further developed with resident involvement. Plans to convert/create two ensuite rooms for the two ground floor bedrooms have been under consideration for sometime and work reported now due to commence. One room has en-suite but shower unit being added, the other does not presently have en-suite facilities but this will be created by using adjoining toilet area, a shower is also to be included. Because a toilet is being “lost” a new one is being created in the area presently used for COSHH storage and that area created elsewhere. The proprietors are asked to submit the proposal with drawings to the Commission and to discuss the implications with the Fire Officer. These proposals are particularly important for residents who do, or may have difficulty in future, accessing the first floor bathroom. Since the last inspection the flooring in the dining area has been replaced with good quality vinyl flooring, improving the appearance and infection control. An extractor hood has been installed over the cooker in the lower ground floor kitchen area. Furniture, equipment and décor is to a good standard with ongoing redecoration of all areas. Some bedrooms were sampled escorted by residents, who were generally satisfied with their bedrooms and furnishings. Some rooms are large others relatively smaller. All were extremely well personalised and had the usual range of TV/CD/DVD/Video/music facilities. Three residents have purchased digi-boxes increasing the number of viewing channels. One has playstation. Personal effects were in abundance including poster, photos and general individual memorabilia. A resident admitted one week ago has few personal possessions but this is being pursued with relatives at this time. There are locks on all bedroom doors and residents seen to access them with their keys. Locks can be over-ridden in the event of emergency. Standards of hygiene in the home were good throughout. There are no domestic staff, residents assisted by staff are responsible for cleaning bedrooms and other areas as part of development of social skills. The laundry area was inspected and adequate for its purpose. All residents wash, dry and iron their own clothing and linen with staff supervision. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 – 36 Staffing levels are adequate for the dependency levels of the current resident group and allows required flexibility to meet agreed activity programmes. Staff engagement with residents was seen to be good residents with spontaneous conversations and relaxed exchanges. Staff files were not seen and recruitment procedures not inspected on this visit. A requirement is made to review the induction process and ensure it is to NTO Standards. EVIDENCE: All staff have job descriptions with clearly defined roles. Staff have access to policies/procedures but some signatures that they had seen and understood them were missing at the time of the last inspection. A recommendation for the Manager to review, update and sign all policies procedures has not be actioned and this is further recommended. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 21 The home maintains the required staffing level of around 550 per week, although there have been minor variations to this recently with reduced occupancy. There are now six people in residence, a seventh expected soon. The staffing levels have now reverted to those required for full occupancy. There are generally three often four staff on duty throughout the daytime and two waking night staff. The numbers of daytime staff support the varied activities and programmes of residents and seem adequate for the needs of the current resident group. The home reached the required 50 of NVQ trained staff at the time of the last inspection. Further NVQ training is in process. Staff training is ongoing – since the last inspection there has been a Team Building day, internal course in Social Skills Therapy and external course relating to Vulnerable Adults. Two Senior staff have undergone Fire Training Course. Staff meetings are held regularly (minutes not seen on this visit). Induction procedures and documentation were not satisfactory at the time of the last inspection in relation to content, extent of work and recording. It was recommended that that induction procedure should be reviewed to provide evidence of the level of training and to ensure it is to NTO Standards. This has not been done and a requirement is therefore made in this report under Regulation 18(1). There are presently two staff vacancies which are advertised, additional cover being carried out by existing staff. There have been no new staff appointments since the last inspection, therefore staff files were not inspected on this visit. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 - 43 The home is well run and there appears an open management style. Residents meeting should be resumed as a means of residents formally expressing their views about the operation of the home. Policy/procedure is required for Food Safety & Nutrition. All policies must be regularly reviewed monitored and amended by the Manager. Fire drills should be three monthly for all staff engaged in night duties. The names of staff members must be recorded in the record of the drill. The induction training programme must be reviewed to ensure it is to NTO standards. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 23 EVIDENCE: The Registered Manager has the required experience to run the home. She is presently engaged in study for completion of the required Registered Managers Award. There is an open management style. Regular staff meetings are held and staff appear committed and have good relationships with residents and with colleagues and manager. The home is visited monthly by the Responsible Individual from Acorn Care Ltd (owing company) and report is left in the home (not seen on this visit). Residents meetings should be resumed as a formal method of involving them in decisions affecting the daily running of the home. Policies & Procedures have not been reviewed for sometime and the Manager should ensure regular review as prescribed in Standard 40.6. A requirement of the last report to provide a policy/procedure relating to Food Safety & Nutrition has not been actioned and is a further requirement of this report. Fire records were inspected and regular checks of the alarm system and equipment had been carried out. It was noted, however that fire drills are recorded approximately six monthly. The record is signed by the person leading the drill, but there is no indicated of which and how many, members of staff/residents were involved. A requirement of this report is to provide three monthly fire drills for all staff and records must record which staff are involved. Annual fire training has been provided for staff following previous requirement. Risk assessments are in place relating to resident activity, but as stated previously in this report some require updating and regular review. The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 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 3 2 3 3 3 4 3 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 x 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 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 2 2 2 2 x The Woodlands, DS0000005028.V282800.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA42 YA35 Regulation 16(2)(j) 18(1) Requirement Provide policy on food safety & nutrition. –Previous timescale not met. Review induction procedures & documentation to provide evidence of induction to NTO Standards Copy of Guardianship Orders must be available in the home to validate legal status of residents Three monthly fire drills must be provided for all staff & record kept of staff members involved. Timescale for action 31/03/06 30/04/06 3 4 YA6 YA42 15 23(4) 09/02/06 09/02/06 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 YA24 YA8 YA6 Good Practice Recommendations Submit proposals with drawings for planned internal rearrangement of the premises and discuss same with the Fire Officer Regular residents meetings should be resumed Provide training for staff in use of new care planning information system. DS0000005028.V282800.R01.S.doc Version 5.1 Page 26 The Woodlands, Commission for Social Care Inspection Stafford Office 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, DS0000005028.V282800.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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