Inspection on 28/11/07 for Woburn Sands Lodge

This inspection was carried out on 28th November 2007.

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

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 Woburn Sands Lodge 60 Station Road Woburn Sands Milton Keynes Buckinghamshire MK17 8RZ Lead Inspector Nancy Gates Unannounced Inspection 28th November 2007 12:30 Woburn Sands Lodge DS0000070445.V348769.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 Woburn Sands Lodge DS0000070445.V348769.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. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woburn Sands Lodge Address 60 Station Road Woburn Sands Milton Keynes Buckinghamshire MK17 8RZ 01908 587677 01908 587867 woburnsands@goldcareltd.com 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) Gold Care Group Ltd vacant post Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia (MD). The maximum number of service users to be accommodated is 10. Date of last inspection Not applicable Brief Description of the Service: Woburn Sands Lodge is managed by Gold Care Ltd and was registered in July 2007 to provide residential and nursing care to adults who have a primary mental health need of a chronic and enduring nature. The home is registered to provide accommodation and support for up to ten people The home is situated in the town of Woburn Sands on the outskirts of Milton Keynes. There are shops within easy walking distance and there are public transport links (bus and train service) to Milton Keynes and Bedford. The house has been extensively refurbished to meet individual needs. There is a kitchen, lounge/dining room and a separate smoking room. All of the bedrooms are single; some have an en suite toilet and shower. The home has a rear garden with a seating area to the side of the property. The current scale of fees for this service is £1100 to £2011.66 per week. Please contact the provider to establish how these fees are applied. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the service was a surprise visit and was a ‘key inspection’. The inspector arrived at the service at 12.30 p.m. on a weekday. The total number of hours spent at the home was 8 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information from an Annual Quality Assurance Assessment, completed by the service manager and also took into account information that CSCI has received about the service since the registration of the home in July 2007. We asked for the views of seven people who live at the home and also asked the views of others who support the needs of the people who use the service via a questionnaire/survey that we sent out. A total of seven surveys were returned to us, five from the people who live at the home, one from relatives/carers/advocates and one from professionals (care managers, health professional’s and GP’s.). All information received by the Commission for Social Care Inspection since registration, about this service was also taken into account when producing the key inspection report. Staff and the people who live at Woburn Sands Lodge were very welcoming. Discussions with two staff members, the manager, the area manager, the Responsible Individual, two relatives and three people who live at the home took place within the site visit. We looked around the home including the bedrooms of individuals at their invitation. A number of records were viewed including individuals care plans, staff recruitment records, staffing rotas and maintenance/health and safety records. We looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. Wewould like to thank the manager and staff team for their assistance with the inspection. Thanks also to the people who use the service, visitors and all others who shared their experience of this home. What the service does well: Prospective residents are given information that will help them make an informed choice about whether to live at the home. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 6 There is a clear and detailed assessment process to ensure that all prospective residents support/care/nursing needs are assessed. The process ensures that the service is able to meet people needs before they move in. Care and support plans are based on detailed assessments of peoples needs and support the good quality care provided by staff. The people who live at the home are also enabled to take risks, in order that they are as independent as possible. Service users are offered a good diet, in order that nutritional needs are met. Personal and healthcare needs are appropriately supported. Staff continue to provide personal support in ways, which people prefer, in order that their needs are best met. Staff clearly promote individuals’ physical and emotional health, to keep them healthy and well. Access to additional support from health care professionals is consistent and meets health needs. Five people who live at the home responded to a survey and told us that they are happy with the support they receive, adding that they felt that staff know when they are unhappy. Feedback from families and healthcare professionals was also positive, “They have been superb…fantastic at communicating with us…process from the start was quick and professional…you could tell as soon as you walked in the door that staff were knowledgeable and skilful, they know what they’re about…X came here and it’s changed his life.” Needs arsing from equality and diversity are well met. From the evidence seen, we consider that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. The storage and administration of medication ensures the protection of individuals. Medication practice is well managed at the home, to ensure that health and well-being are promoted. A clear complaints process is available to the people who live at the home and their representatives. There continues to be an effective complaints procedure in place, to listen to the views of individuals. Protection of the people who live at the home is assured by the availability of adult protection guidance, appropriate training and staff awareness. A pleasant and comfortable environment is provided for the people who live at Woburn Sands Lodge. People’s bedrooms reflect individuality. The design and layout of the home, including adaptations and equipment meet individual need. The home is clean and hygienic, continuing to guard against the risks of infection and ill health. Staff are attentive and respectful promoting communication and independence in relation to need and abilities. Competent and qualified staff work at the home. Training provided to staff ensures that they are competent and Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 7 qualified to meet individual needs. Staff records indicate that the recruitment process ensures the protection of residents. A manager has been appointed at the home to provide leadership; guidance and direction to staff to ensure residents receive consistent quality care. An application for registration must be submitted. There is regular monitoring by the provider, to ensure that the home is efficiently run and providing good standards of care. Records are generally well-maintained. The manager has a good understanding of the needs of the people who live at Woburn Sands Lodge and has worked for the organisation for a number of years. The manager’s skills and experience are supported by nursing and management qualifications. Staff described the manager as being very supportive and knowledgeable, defining clear boundaries of nursing and support offered at Woburn Sands Lodge. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woburn Sands Lodge DS0000070445.V348769.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 Woburn Sands Lodge DS0000070445.V348769.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): 1, 2, 3, 4 & 5 Quality in this outcome area is good Prospective residents are given information to help them make an informed choice about the service. The home has an assessment procedure to ensure that prospective residents’ needs are assessed and that the home can meet those needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A statement of purpose and service user guide are in place to inform prospective residents of what is offered at the home. The statement of purpose provides details of the registered provider and the manager including details of their qualifications and experience. It provides information regarding the organisation, information about the service on offer, admission to the home, the accommodation provided, how peoples’ views will be listened to, the staffing structure and details of the complaints procedure. The service users’ guide reflects the contents of the statement of purpose with the addition of information about contracts and agreements for residency. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 10 The manager confirmed that a copy of the inspection report would be made available to both the people who live at the home and their families/representatives An additional brochure is also available providing the initial but very descriptive information about what the home/service has to offer. The information provided to prospective residents includes very clear descriptions of the nature of need that can be supported e.g. Schizophrenia, depression, anxiety, bipolar disorder and schizo-affective illness. Referrals to Woburn Sands Lodge are undertaken through the Care Programme Approach (CPA) process (Mental Health Act 1983). Individuals discharged from a hospital setting under specific sections of the Mental Health Act 1983 can be and are accommodated at the home. Documentation provided within the CPA process inclusive of care management information provides clear descriptive assessment of needs, allowing for clear judgement of need prior to admission. A referral assessment, inclusive of identifying risk factors and mental health diagnosis is completed by the manager with the prospective resident and professional contacts. We looked at the admission records for four people and they showed that a clear, standardised admissions process involving the individual and relevant professionals at all stages in undertaken. The completed assessments highlight the importance of clear risk management strategies prior to admission and how the strategies can ensure that an individual is supported to take risks whilst remaining within the remit of their care plan Introductory visits are arranged, providing the prospective resident, the manager and staff at the home and the referring professional to decide whether the home is likely to be able to meet the prospective user’s needs. Admission is then agreed. An ‘Admission Agreement’ states that the first 28 days of residence are regarded as a trial period, with a review conducted at the end of this period to decide whether “in the mutual interest of both parties the long-tem placement should be confirmed.”. The admission agreement is clear and defines the terms and conditions of admission including information regarding fees. Fees are agreed with the placing authority and the information is provided to the prospective resident by their care manager/supporting professional contact. The agreement is signed and dated by the prospective resident and/or their representative and the service. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 11 The current scale of fees for this service is £1100 to £2011.66 per week. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Quality in this outcome area is good A comprehensive care plan remains in place for each individual. Care plans include assessment of needs, plans to provide support where required, and evidence of liaison with health and social care agencies in the community. The plans aim to ensure that individuals’ needs are met and that they are supported in maintaining their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care plan files of four people who live at the home. The files contained assessment information including Care Programme Approach (CPA) plans, discharge documents and care plans. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 13 The files contained a number of clear assessments and plans relating to the support needs of individuals, for example, CPA assessments, risk assessments, information regarding physical health, mental health, legal requirements, education/courses, employment opportunities and daily notes (recording significant events). There are clear accounts of individual skills; any ‘unmet needs’ are and can be highlighted within reviews. Daily records show that staff are aware of the need to be non-judgemental, positive and respectful, and to highlight strengths. Reviews are undertaken on a regular basis, confirmed not only by the people who live at the home but also within written information in individuals’ files. Information contained within the documentation focuses on issues identified by individuals in consultation with nurses and healthcare professionals. Goals/aims are monitored by nurses to ensure that they remain realistic. Restrictions are reflected within the admission agreement, agreed and signed by all relevant parties. We met with three people who confirmed to that they felt able to make decisions about many areas in their life. Any restrictions identified within the risk assessment process were considered reasonable and geared to ensure their safety and ensure that the interests of all of the people who live at the home were best met. People confirmed that they are supported in participating in home life and in making decisions. This is achieved through activity plans, participating in the cleaning rota, participating in the house meeting and in menu planning. The manager has made contact with ‘People’s Voices’, a local advocacy service to ensure that independent support can be provided to individuals upon request. One person uses a legal representative to act on their behalf. Risk assessments are an essential part of an individuals care plan. Assessments clearly relate to care contracts/agreements. Clear and concise risk assessment and guidance is tailored to individuals’ support needs, including discussion with an individuals care team to identify ‘positive risks’. People confirmed that they participate in the risk assessment process. Arrangements for managing and storing confidential information for the protection of all household members and staff are satisfactory. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good The people who live at the home participate in a variety of social, therapeutic and recreational activities which aim to meet individual needs, improve wellbeing and establish positive networks of support in the wider community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The information provided to people about what’s on offer at the home states that a range of activities, conselling/1:1 individual work and group therapy is facilitated by a member of staff. Listed activities include, art and craft, social skills group, news and views, gardening, music and sensory group and trips out. Activities run alongside opportunity for individual and group therapy sessions. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 15 We looked at the support plans of some of the people who live at the home and took the opportunity to talk with them about the educational/social activities available. Individuals’ preferences and wishes are recorded in their care plans. The home stresses the importance of structure to each person’s day and week, a matter, which is of particular importance in a service where there is an expectation that the service will support people to maximise their skills for independence. We spoke with two people and some family members about what the home has to offer, each person was very positive about how their preferences and interest are prioritised and supported. One person is undertaking an NVQ in Support Services; another has attended local college courses due to their interest in cookery. One person enjoys weight lifting/body building and will go to the gym on a regular basis, some people enjoy going out for something to eat or for a drink, however the admission agreement makes a clear statement about the use of alcohol and a placement review would be completed if excessive usage became an issue. People go swimming and go shopping in Milton Keynes. A beautician will visit the home on a regular basis offering discounts for treatments. The home has been open for only a short period of time but the manager has established contact with and made referrals to the Richmond Fellowship for Employment and Training (RFET). A number of people have shown an interest in finding employment and have agreed to the support from the RFET. Others have shown interest in attending ‘Re-Think’, a community service offering a range of activities for people with mental health support needs. This mix of activities provides structure, supports participation in communal activities, establishes and maintains links with a network of support services in the community and supports integration with the local community. A number of people are in contact with their families. The nature and extent of the contact varies, but all visitors are welcomed. There are no restrictions on where people can receive visitors, however this would depend on individual support needs and would be assessed in relation to issues of vulnerability. We took the opportunity to speak with family members who relayed very positive views of the support and structure offered at the home. Family members said that they felt confident that the staff are able to support needs, that they are respectful and will relay important information if needed but only with the permission of their relative. Meals are planned with the people who live at the home, usually within the house meeting. A four-week rota is written and includes contributions from as many people as possible. A chef has been employed to prepare and cook the Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 16 main meals of the day but people are encouraged to cook for themselves if they want an alternative to the choices on offer. Breakfast is self-service – usually cereals, toast, boiled eggs, fruit and drinks (fresh juice, teas, coffee). Lunch is usually the cooked meal of the day, however people can opt for a hot meal in the evening. The evening meal is usually sandwiches or a light snack. A varied selection of meal options is made available and two choices are offered at lunch. Drinks and fresh fruit are available; the people who live at the home are encouraged to “help themselves”. Specialist dietary needs are assessed and supported appropriately, additional guidance can be sought from a dietician. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good Personal and healthcare needs are appropriately supported. Needs and wishes are respected. Access to additional support from health care professionals is consistent and meets health needs. Medication is stored securely and administration is accurate, ensuring individuals safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of people who live at Woburn Sands Lodge do not require ‘hands on’ assistance for personal hygiene issues, however individuals can be guided and encouraged to maintain a reasonable level of personal hygiene dependent on their needs. Assessed needs are recorded within care plans. Access to professional and clinical support is offered through the Care Team/Community Mental Health Team (CMHT). The monitoring of individuals mental health needs is undertaken with the Community Mental Health Team (Care Team). Professional visits are encouraged and welcomed with outcomes recorded when appropriate. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 18 Reviews are undertaken on a regular basis, meeting both personal and legal obligations. Care plans and daily records highlight the ongoing contributions to plans and reviews undertaken by the individuals and staff. We received information from healthcare professional who are in contact with the home. Extremely positive comments were received regarding the quality of the service provided. “They have been superb…fantastic at communicating with us…process from the start was quick and professional…you could tell as soon as you walked in the door that staff were knowledgeable and skilful, they know what they’re about…X came here and it’s changed his life.” People confirmed that they registered with a local GP. A brief description of the outcomes of each visit can be recorded with individual’s permission when appropriate. Medication administration and recording is of a good standard. Individuals’ agreement to take medication is recorded within CPA documentation. Individuals receive medication on a singular basis from the medication storage cupboard situated in the ground floor corridor. Medication is stored within a locked trolley/cabinet and at the correct temperature. A local pharmacist supplies the home with medication stored within a dispensing system. All medication entering and leaving the home is recorded to ensure the safety of the people who live at the home. Medication administration records are supplied by the pharmacist to support accurate administration and recording. Recording is accurate, no omissions were noted. Medication administration is only completed by qualified staff (nurses). No ‘controlled drugs’ are currently used but can stored and administered within a safe system if required. Staff confirmed that a clear medication policy and procedure is available at the home and that medication training and tests have to be undertaken to ensure competency in dispensing and recording. Spot checks are completed on a monthly basis by the manager to ensure a safe system is maintained. The home has a policy to guide staff action in relation to the care of a dying person or in the event of an individual’s death. The manager stated said that the home would liaise with relevant healthcare services in the community, however due to the sensitive nature of the subject discussion with the people who live at the home has not been undertaken. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good A clear complaints process is available to listen to the views of individuals and their representatives. Protection of the people who live at the home is assured by the availability of adult protection guidance, appropriate training and staff awareness. The protection of individuals is assured by staff as far as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No formal complaints have been received at the home or at the CSCI since the registration of the service in July 2007. Concerns have been raised with the CSCI but were not substantiated. A complaints procedure is in place, which forms part of the service users guide. The people who live at the home and their relatives have access to this procedure. The procedure clearly explains the process and timescales for response. Individuals and their families/representatives confirmed that they have been provided with a copy of the complaints procedure within the service users’ guide/handbook. People also confirmed that they are happy to talk to staff if needed and are aware that an issue ‘can be taken further’. We received a number of comment cards from relatives/visitors who confirmed that they are aware of the complaints procedure. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 20 A whistle blowing and a Safeguarding/Protection of Vulnerable Adults policy and procedure are in place. Staff training records showed that the majority of staff have received training regarding the Protection of Vulnerable Adults, the remaining staff are due too attend the training in the near future. Staff spoken with were able to provide a good account of how to respond to allegations. The home has facilities for storing individuals’ money if required, but ‘money management’ is not provided. Small amounts of cash may be held on behalf of an individual, all transactions are recorded i.e. balance, money taken out, money returned. The signature of the individual is obtained for all transactions. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is good A clean, safe and well maintained environment has been created, providing people with a comfortable and homely place to live, suiting the needs of the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is located on a main road in the in a quiet residential area. Milton Keynes is approximately 6 miles away, accessible by public transport or by use of the house car. There is limited parking to the front of the house but additional parking is available to the rear of the property. Alternative parking is available on nearby roads. There are local shops and a pub a short walk away. Woburn Sands Lodge has been re-decorated and refurbished to a good standard. All areas seen within the main areas of the home were clean and Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 22 comfortable, providing living areas, which are light, well heated whilst also providing good ventilation. An entrance hall leads to the lounge/dining room, a ground floor bedroom (with en-suite facilities), a smoking room (which is ventilated), the kitchen, a cloakroom/visitors toilet, a bathroom, a laundry room, a further three bedrooms (with en-suite) and a small office. There is a garden with seating to the rear of the property. The lounge/dining room is comfortably furnished and is sufficient in size for current use. The kitchen is domestic in scale. It is equipped with wall and floor mounted storage cupboards, work surfaces, cooker, refrigerator, freezer and dishwashing facilities. The kitchen facilities were tidy and in good order on the day of the site visit and are sufficient for current use. Stairs lead to the first floor accommodation, which comprises of a further six bedrooms (3 with en-suite facilities), a bathroom, a toilet and a ‘clinic room’/small office. Bedrooms vary in size. According to information provided by the provider, two bedrooms are under 12 square metres in size. The bedrooms provide people with a comfortable personal space and contain good quality furniture, linens and floor covering. The rooms were observed to reflect the personal tastes of the individuals, containing personal belongings that give the rooms individual identity. All of the shared spaces within the home are accessible for shared and private use. We talked with two people who live at the home and they stated that they are “happy” with the living space; they also acknowledged the shared responsibility to keep the home clean and tidy even though a housekeeper is employed at the home. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good Woburn Sands Lodge has an appropriate level of staffing to support the needs of the people who live at the home. Recruitment procedures ensure the protection of the people who live at the home. Staff skills, appropriate training and supervision meet the needs of the people who live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Job descriptions are in place for all staff defining clear roles and responsibilities to support the people who live at the home. Woburn Sands Lodge has an appropriate level of staffing to support the needs of the people who live at the home. The on site staff team comprises of 5 qualified nurses, 9 health care assistants/support workers, a housekeeper and Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 24 a chef. The staff team were enthusiastic and motivated, offering respectful support to individuals. Staff spoken with were clearly knowledgeable regarding the needs of people who have enduring mental health needs. A number of staff described how courses provided by the organisation have support their development and knowledge. Staff described a robust recruitment and selection process conducted by the provider. It is clear that the selection of employees ensures that competent and motivated people are available to support individuals at the home. We looked at six staff files, which contained the information required for recruitment and for the protection of the people who live and work at the home. The manager confirmed that two written references are obtained before the commencement of employment. Criminal Record Bureau checks, including POVA first are completed centrally within the organisation, appointments confirmed following the receipt of acceptable references and CRB check. All new employees undertake a induction programme, inclusive of the required courses to ensure the safety of household members i.e. first aid, fire safety, health and safety, food handling and hygiene, protection of vulnerable adults. An induction pack is provided; performance reviews initially linked to the probationary period are regularly conducted to ensure that staff are competent to support the needs of the people who live at the home. The manager confirmed that all staff would be provided with a copy of the General Social Care Council (GSCC) codes of practice on appointment. Internal and external training opportunities are offered to employees, relating to the identified needs of the people who live at the home. Training records confirmed that the staff group have a mix of skills and knowledge to support individuals’ needs. Information received from the provider shows that of the 10 permanent and 3 bank staff 11 staff are qualified to NVQ level 2 or above, indicating that 85 have achieved the required standard of qualification, exceeding the 50 stated within the standard. Records showed that supervision is being undertaken for all staff. Supervision notes record performance, progress and action required within an individuals work role. Training and development issues are identified within the supervision format. Appraisals will be conducted every year. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 & 43 Quality in this outcome area is good The home is well managed and staff work as team, which benefits household members. The organisation has systems in place to monitor the quality of care and to ensure that standards are being maintained. Health and safety practices safeguard the people who live at Woburn Sands Lodge This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has a good understanding of the needs of the people who live at Woburn Sands Lodge and has worked for the organisation for a number of Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 26 years. The manager’s skills and experience are supported by nursing and management qualifications. Nursing and management within the home is supported by a team of qualified nurses ensuring the home is appropriately managed at all times with an on call system in place. The Responsible Individual stated that an application for registration will be submitted by the manager in the near future to ensure that the day-today and ongoing development of the service is managed effectively. Staff described the manager as being very supportive and knowledgeable, defining clear boundaries of nursing and support offered at Woburn Sands Lodge. Regular visits to the home are completed by the provider to look at the quality of care/support. Reports of these visits are held at the home. The people who live at the home are provided with a questionnaire, giving them the opportunity to “have their say” about how they are supported at the home and whether their needs are being met. Families/representatives are also asked to provide information about the quality of the service offered at the home via a questionnaire. As the home has only been registered for under six months, it is too early to assess the effectiveness of the quality assurance process. Health and safety is promoted; training is provided to staff in induction and it is proposed that all staff will have regular training/updates. Records held in relation to health and safety viewed at the site visit are accurate and up to date, promoting the safety of all household members. COSHH materials are stored in a locked cupboard and the relevant data sheets are available in a health and safety file in the office. Systems are in place for recording accidents. The fire log showed that routine tests are carried out and that maintenance and servicing takes place. Additionally a fire based risk assessment was in place. Staff receive fire safety training every year. Recommendations from the fire service have been undertaken including the replacement of a door at the top of the stairs to include vision panels. Generic and individual risk assessments are in place for all identified risks, inclusive of safe working practice. The procedure for recording and reporting of incidents and accidents is satisfactory. Policies and procedures relevant to the conduct of the home are available. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 27 The provider stated that there is a business and financial plan for the service and that relevant insurance cover is in place. Lines of accountability are clear and an organisation chart is included in the home’s statement of purpose. Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 28 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 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 4 3 3 3 3 3 Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Not applicable STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Woburn Sands Lodge DS0000070445.V348769.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!