Inspection on 03/11/05 for Wood Dene

This inspection was carried out on 3rd November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wood Dene 06/11/06

Wood Dene 01/06/05

Wood Dene 01/12/04

Wood Dene 11/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Wood Dene Colliery Approach Outwood Wakefield West Yorks WF3 3JH Lead Inspector Tony Railton Unannounced Inspection 3rd November 2005 11:00 Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 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 Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 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. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wood Dene Address Colliery Approach Outwood Wakefield West Yorks WF3 3JH 01924 825252 01924 871972 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) Life Links Limited Mrs Joanne Lunn Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 2005 Brief Description of the Service: Wood Dene continues to provide accommodation and personal care for 16 people who have a learning disability and in particular Autistic Spectrum Disorder . Specialist training is provided for all workers and autism specific day care services are also offered on a different site close to Wood Dene. All people living in the home have their own room which is en-suite. Wood Dene comprises of two eight bedded units each with its own kitchen, lounges and dining rooms. The care provided is based on ordinary living principles and there is an expectation that people do as much for themselves as possible within an agreed planned framework. Set back in its own grounds the home is situated in a residential part of Lofthouse on the outskirts of Wakefield. It has a small garden to the front and a larger garden to the rear. It is close to a main bus route and Outwood Rail Station and the M1/M62 link roads are close by. There are local shops, post office and public houses within walking distance from the home and Wakefield city centre and all services and amenities are only a few minutes journey away. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a short unannounced inspection as most of the core standards were inspected at the last visit to the home. A major change since the last inspection is that the home has a new registered manager Joanne Lunn who became registered with the Commission for Social Care Inspection in October this year. There have been a number of improvements since the last inspection and the home continues to meet to meet all statutory requirements with the exception of one and almost all minimum standards. This was an interesting and informative inspection with the opportunity to speak to three service users, one senior support worker, the registered manager and admin support worker. There was also the opportunity to examine a number of case files, medical records and also information about staff and staff training and supervision records. This was a very positive inspection with improvements to the care management systems noted. The inspector would like to thank service users and staff team for their patience and co-operation throughout the inspection. What the service does well: What has improved since the last inspection? The changes to the physical environment have been considerable since the last inspection. These improvements are to be commended. The new registered manager said that she will make sure that there is a rolling programme of refurbishment, decoration and maintenance to keep the home looking good. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 6 The inspector acknowledged that the behaviour of some with Autistic Spectrum Disorders can be detrimental to the home, nevertheless, an attempt has been made to make the environment as homely and comfortable as possible. The care plans and in particular the risk assessments have improved since the last inspection. The inspector was pleased to note that staff supervision has commenced and that there is a annual programme of line management supervision sessions planned for all staff. On the day of the inspection it was noted that administration staff were reorganising staff records and putting them in a presentable order. Examination of staff files showed that they present well and contain all of the information required by the care homes regulations. 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. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 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 Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 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&2 Service users have a comprehensive assessment of their personal health and care needs before they are offered a service. However, prospective service users and their representatives would benefit by having correct information about who the owners and the registered manager are. EVIDENCE: The assessments used by the home are good and show how people are affected by their disability and what needs to be done to help them and make sure they get the care and support they need. The assessments are behaviour orientated and specifically used in assessing people with an Autistic Spectrum Disorder. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 &9 Some service users have the ability to know and say that they feel their needs are been met and this is reflected in their assessments, care plans and reviews. All service users are supported and assisted to make decisions about their daily lives. EVIDENCE: Service users case files including assessments, care plans and reviews show that some service users are quite able and can comment on, agree and sign their own care plans and review reports. The daily records show that descriptive words are used to reflect and record service users choices and preferences. Although the majority of the daily records are good and use descriptive words there is a need for consistency and service users would benefit from a more descriptive record of what they do and how they influence their day to day lives. Risk assessments show that service users are supported and encouraged to do ordinary things in the community and taking risks is an accepted part of living an ordinary lifestyle. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 10 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): 12,13,15,16 and 17 Service users are encouraged and supported to take full advantage of all local community based healthcare and leisure services. EVIDENCE: Service users care plans and daily records show that they have a real presence in their community. Records show that service users use the local shops, local public house and public transport. Records also show that service users go on holiday and for day trips to the coast, go to the cinema, theatre, restaurants, go swimming, bowling and almost all activities experienced by most people. This is to be commended as some of the behaviours encountered by some service users can be challenging and staff do well in making sure they are included in ordinary community based activities. The activity sheets show that all services users have a programme of activities designed to reflect their personal development, social and emotional care needs. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 11 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): 18,19 Service users receive personal support in a way they prefer and require and their physical and emotional health needs are met. EVIDENCE: Although these standards were inspected at the previous statutory inspection, examination of service users case files, reviews and daily records show that wherever possible service users are fully involved in their care. Records also show that service users have the opportunity to comment about the care they receive at their reviews. Medical records and discussion with the manager and senior support worker show that service users are assisted to take advantage of ordinary community based healthcare services. However, there is the support of specialist Social Workers, Learning Disability Team Nurses and also hospital based consultants and psychologists. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 12 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 Service users know that their views are listened to and acted upon and that they are protected from abuse neglect and self harm. EVIDENCE: It was noted that the home continues to provide and use the Wakefield Social Services and Health Multidisciplinary Adult Abuse Policy and Procedure which forms part of the training for new staff. Discussion with the manager and examination of staff training records show that all support workers have ‘behaviour management’ training and update training on a regular basis. Examination of some service users case files, record of complaints and daily records indicate that service users views and comments are listened to and acted upon. A recent incident reported as a Regulation 37 was discussed at length and the relevant service user and support workers files were reviewed and discussed with the registered manager. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 13 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 Service users live in a homely comfortable and safe environment which is personalised and clean, however, they would benefit further from having a planned programme of renewal and decoration and from knowing that their home will always look good and meet their needs. EVIDENCE: Although a complete inspection of the home was carried out at the last statutory inspection there were a number of improvements to the home observed. The stairwells have been decorated including the banister rails which have been stripped and varnished. The kitchen looks very well indeed with all new drawers, cupboards and fittings, and there is new lounge furniture which is homely and comfortable. A planned programme of maintenance and renewal of the fabric and decoration of the premises was not available for inspection, however, the manager said that she intends to provide one and keep on top of the recent improvements. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 14 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): 32,34, 35 & 36 Service users benefit from clarity of support workers roles and responsibilities and are protected by the staff recruitment and selection process. However, service users would benefit from being supported by suitably qualified and supervised staff. EVIDENCE: Examination of new staff recruitment and selection records shows that all appropriate checks and references are taken up before they are employed. Discussion with the manager and examination of staff supervision records and timetable shows that staff are not receiving a minimum of six line management supervisions per year. Staff training records also show that less than 50 of support workers have a national vocational qualification. The registered manager said that she has employed a number of new staff recently which has affected the percentage of trained staff available in the home. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 15 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): 37,39 & 42 Service users benefit from living in a well run home in which their rights and best interests are protected and their health, safety and welfare is promoted and protected. EVIDENCE: It was noted that the home has a new registered manager. Joanne Lunn was deemed fit by the Commission for Social Care Inspection and became the registered manager this week. Discussion with the manager, senior support worker and examination of staff training records including training matrix showed that health and safety training including Basic First Aid, Moving and Handling, Infection Control and Food Hygiene has a high profile and all staff receive regular planned training and update training. This along with Behaviour management training, risk assessments and health and safety policies, procedures and practices promote the health and safety of service users. Although through the daily records, assessments and reviews show that service users have a say in what happens to them and on the quality of care provided the manager said that service users are not asked their views as part of quality assurance monitoring. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 16 She went on to say that although the organisation has recently developed a service user questionnaire these have not been introduced or given to service users. The manager said that she intends to seek the views of service users their relatives and other visitors on the quality of care provided and publish the results annually. On the day of the inspection there were no Regulation 26 visit reports to see and the inspector commented that the CSCI had not received any regulation 26 reports either. The manager said that she did not have any Regulation 26 reports to show the inspector, however, representatives of the owners do visit the home on a regular basis to discuss how the home is getting on and if there are any problems. Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 17 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 X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wood Dene Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 X 1 X X 3 X DS0000006228.V261500.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? N/A 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 Standard YA39 Regulation 26 (1- 5) Requirement The registered provider or their representative shall visit the home on a monthly basis and provide a report on the running of the home. Timescale for action 03/12/05 Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations Information about the home including The Statement of purpose and service user guide should be updated to reflect the change in responsible individual and management structure and the name of the registered manager. The manager should provide a planned maintenance and renewal programme for the fabric and decoration of the premises. 50 of care staff should hold an NVQ Level 2 or 3 Support workers should receive a minimum of six line management supervision sessions per year and a record maintained for inspection. The results of service users surveys should be published on a regular basis. The views of service users relatives, friends and other stakeholders should be sought on the quality of care provided by the home. 2 3 4 5 6 YA24 YA32 YA36 YA39 YA39 Wood Dene DS0000006228.V261500.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. 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