Inspection on 15/11/05 for Woodacre

This inspection was carried out on 15th November 2005.

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

The inspector 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

Woodacre 27/09/07

Woodacre 18/10/06

Woodacre 17/05/05

Woodacre 16/11/04

Woodacre 30/06/04

Woodacre 11/11/03

Similar services:

Claremont House

Chesham House

Argyll House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

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

CARE HOME ADULTS 18-65 Woodacre 38 D`arcy Road Tolleshunt Knights Maldon Essex CO5 0RR Lead Inspector Kathryn Moss Announced Inspection 15th November 2005 09:30 Woodacre DS0000018000.V253953.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 Woodacre DS0000018000.V253953.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. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodacre Address 38 D`arcy Road Tolleshunt Knights Maldon Essex CO5 0RR 01621 819769 01621 819078 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) Macintyre Care Ms June Elizabeth Woods Care Home 15 Category(ies) of Learning disability (15), Learning disability over registration, with number 65 years of age (2), Mental disorder, excluding of places learning disability or dementia (1) Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One person, under the age of 65 years, who requires care by reason of a learning disability and who also has a mental disorder, whose name was provided to the Commission in April 2004 Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 15 persons) Two persons, over the age of 65 years, who require care by reason of a learning disability, who were accommodated at the home before 1 April 2002, and whose names have been made known to the Commission The total number of service users accommodated in the home must not exceed 15 persons 17th May 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Woodacre is a residential home for up to 15 service users, situated in a village location a short distance away from the town of Tiptree. The home consists of three ‘Houses’ (referred to as Elm House, House 3 and House 4), each with a ground floor and first floor, providing: five single bedrooms, two bathrooms, a lounge, kitchen diner, conservatory area, and a garden area. A fourth building on site is used for day services and office space, and there are extensive grounds. There are dedicated day services staff employed at Woodacre. Woodacre is run by Macintyre Care, and the property is leased from the area health authority. Each house has a ‘head of service’: at the time of this inspection, and the head of service for House 4 is currently the registered manager on behalf of the overall home. Woodacre provides accommodation and care to service users whose primary needs result from a learning disability, although some service users have an additional physical disability or sensory impairment. One service user has mental health needs, which is reflected in the home’s conditions of registration. The home is registered for adults under the age of 65 who have a learning disability (LD), but due to the fact that the home aims to be a home for life, a few of the residents who have been there since the home was established in 1991 are now over the age of 65. This is also reflected in the home’s conditions of registration. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over two days, starting on the 15/11/05, and lasting eleven hours. On the day of the inspection, there were thirteen service users in residence at Woodacre: four in Elm House and in House 3, and five in House 4. The inspection process included: discussions with all three Heads of Service and with seven other staff; time spent with four service users; discussion with the relatives of two service users, and an advocate; the viewing of communal areas; and inspection of a sample of records. 19 standards were covered, and 4 requirements and 10 recommendations were made. Information on core standards not covered on this inspection can be found in the previous inspection report of the 17.5.05. During the inspection, staff were caring and patient with service users, demonstrated a positive and enthusiastic approach, and were informed and knowledgeable about the needs of service users. Service users were spending time with staff and were engaged in a variety of activities. What the service does well: What has improved since the last inspection? The Service User Plans in House 3 had greatly improved since the last inspection, showing good work by staff to develop these and to describe the action needed to support service users in meeting their needs and daily routines. The home’s Day Services has been undergoing development this year, and good progress had been made with this, including: the development of more in-house activities and ‘courses’, the development of the rooms and resources in the Day Services Unit, identification of service users’ likes and interests, Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 6 recording of activities, and the opening of the Coffee Bar at the end of the afternoons and for social events. Several staff commented on the positive impact this was having. The home continued to provide good opportunities for holidays, including facilitating holidays for individuals. In particular, two staff had supported one service user to visit family who lived abroad: this had been well planned, and although quite challenging, had been very successful and a positive experience for the service user. Some major refurbishment had taken place this year in several of the Houses, including new kitchens and patios in two Houses, as well as some internal decoration and new carpets. This had made significant improvements to the environment. 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. Woodacre DS0000018000.V253953.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 Woodacre DS0000018000.V253953.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): None EVIDENCE: None of these standards were specifically inspected on this occasion. It was noted that one Service User Agreement had been produced in a Makaton pictorial format for a service user, and the manager confirmed that the link worker had also communicated the content of this to the service user using Makaton to assist them to understand it. This is a good example of the home trying to make information available to service users in appropriate formats. Woodacre DS0000018000.V253953.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 and 8 Service users’ needs and goals were reflected in their individual plans, and the home promoted a person centred approach to care planning. Decision making by service users was encouraged and supported in the home, and decisions made by staff on service users’ behalf were based on knowledge of the person. EVIDENCE: Sample care plans were viewed in each House. It was noted that extensive work had taken place on care plans in House 3 since the last inspection, to address issues raised at that time. Files had been reorganised and all care plans re-developed: these now provided comprehensive information on all daily needs/routines, including health, personal care and activities; a separate activities of daily living care plan had been produced in a pictorial format to show different activities and choices. Staff are commended for the work done to improve these. House 4 care plans clearly addressed all needs, with detailed action describing how the person wanted their needs to be met, and with some good care plans addressing health care needs (e.g. for epilepsy and diabetes). Care plans had been reviewed and dates of reviews were shown on care plans, although no record of the outcome. One care plan had been produced in a pictorial format at the service user’s request. It had been noted Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 10 on a previous inspection that Elm House had some good behavioural support plans for individuals with challenging behaviour. Files viewed on this occasion contained an appropriate range of care plans, although some would benefit from more detail of the action required to meet the need; not all were dated. The home operates a link worker system, and service users spoken to were aware of who their link worker was, and positive about them. Staff were attending training in person centred planning, and in one house a link worker had helped a service user to develop some wall charts to illustrate aspects of their person centred plan. The service user was clearly pleased with these. Decision-making about day-to-day issues and personal issues was encouraged within the home: there were examples of staff providing service users with advice, information and choices (e.g. advice about dietary needs in relation to someone newly diagnosed with diabetes). Staff spoken to showed good awareness of different individuals’ likes and dislikes, and were able to describe how decisions and choices were made for individuals who could not do this for themselves. As part of the development of Day Services, some good work was taking place to identify what activities service users liked, to enable appropriate choices to be offered. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 11 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, 14, 15 and 17 The home offered a variety of appropriate activities, in and out of the home, thus enabling service users to take part of valued and fulfilling activities. Leisure interests were encouraged and supported. Service users were encouraged and supported to maintain appropriate relationships with family and friends. The home offered choice of food and diet; however, through personal choice some individuals’ diet lacked balance and should be monitored. EVIDENCE: The home is developing the Day Services unit, and showed good progress with this. A computer and digital camera had been obtained for use by service users, Day Service’s rooms had been redeveloped for specific uses, and the Head of Day Services was planning to attend a course in the use of multisensory rooms. Support staff were becoming more involved in Day Services, with work in progress to identify staff skills in this area. Profiles were being developed on all service users to find out their likes and dislikes, and weekly programmes were developed to reflect individual needs and wishes. Day Services was developing an increasing range of activities, including short inhouse courses with clear aims and outcomes. Service users also continued to Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 12 attend a range of outside courses and activities, and it was good to see that one person had begun some voluntary work, supported by staff. Records of each person’s weekly activities, and the outcomes, were now being maintained by Day Services; it was recommended that the registered person explore how this information can be linked to individual care plans and records. The Day Service’s Coffee Bar was now open at the end of the afternoons and had been used for a Halloween party for the whole home, and staff felt this was positive. On the day of the inspection, service users were engaged in a variety of activities including: making cakes and lunch in Day Services for the rest of the House, going out shopping with link worker, out for a drive, and participating in Day Service activities. One person was visited by their advocate, who was positive about the person’s placement at the home. It was noted that staff had supported one service user to develop links with a church in Colchester, and another was supported to attend a local church. A variety of holidays had been arranged within the home this year, both for individuals and small groups, and illustrated the person centred approach promoted by the home. A staff member spoken to in Elm House was enthusiastic about a recent holiday with one service user, and was able to describe positive outcomes for this person. Of particular note was the considerable effort taken by two staff to assist a service user in House 4 to visit relatives abroad, with evidence of very good planning to ensure that this was carried out professionally and safely. The staff involved were enthusiastic about this experience, which had clearly been very successful. In House 3 the head of service was trying to obtain a passport for a service user to enable the opportunity to take them abroad. There was good evidence of the involvement of families, and of staff supporting service users to maintain contact with families. One person’s relatives visited on the day of the inspection to tell the inspector how pleased they were with all aspects of the home, and another person’s relatives phoned the inspector to commend the home for the care and support it was providing. It was noted that another relative visited regularly and was involved in aspects of the daily life of the home (e.g. recently joined in a session making Christmas cards), and that the staff supported another person to manage regular phone calls to their relatives. Sample menus (meals records) were submitted with the pre-inspection questionnaire: these showed a variety of meals being provided, and reflected individual choices. However, from the records some peoples’ diet did not always appear to be well balanced: whilst it is right that service users have choice over what they eat, it is recommended that heads of service review menus to check whether individuals are getting a balanced diet, and consider ways of encouraging individuals to take a more balanced diet. This issue had also been highlighted at the last inspection, and from discussion with staff on this inspection it did not appear that any specific action had taken place to address this, although the registered person was endeavouring to arrange training for staff in diet and nutrition. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 13 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 and 20 Service users were receiving appropriate support with their personal care, resulting in personal care being well maintained. The home provided appropriate support to meet physical and emotional health needs, accessing the necessary medical support and advice to promote service users’ health. The home has appropriate procedures for the safe management of medicines in the home; however, evidence of staff training in this area was not satisfactory. EVIDENCE: Care plans contained clear information on how to meet each person’s personal care needs (see Standard 6), and were person centred and individualised to reflect individual wishes and preferences. Service users spoken to were happy with the way that staff supported them; all had a dedicated link worker, who they seemed to like and relate well to. Staff spoken to clearly described the importance of enabling and encouraging independence in the way they supported care needs. Service users were individually and personally dressed, and examples were seen of service users being supported to go out shopping for clothes, attend hairdresser appointments, etc. Several care files were seen to contain a Health profile, clearly detailing a list of health care professional involved with the person. Health care needs were Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 14 being appropriately met, with staff supporting service users to attend appointments, and providing appropriate monitoring and support of medical conditions (e.g. epilepsy and diabetes, reflected in care plans). Two staff were due to attend diabetic foot care training. In one House where two service users suffered with epilepsy, records indicated that less than half the staff had attended training on this condition, and this should be reviewed. Staff had taken appropriate action earlier in the year to support one person’s mental health needs, and there was evidence on the inspection that they had strategies for addressing challenging behaviour, and dealt with incidents calmly and professionally. The home had a clear Medication policy/procedure, covering all relevant issues. Most medications were supplied in a Monitored Dosage System, with Medication Administration Records (MAR) pre-printed by the pharmacist to reflect each prescription. In two Houses the medication was stored in locked cabinets in each person’s bedroom, and in another House it was stored in a central locked cupboard. Medication records were only viewed on two Houses, and in both cases records of medication administered were well maintained. Medication received by the home was recorded on the MAR; where no new medication was supplied, medication carried over from a previous month was not being recorded in one House, and in the other House was being recorded on the reverse of the MAR, although in one instance quantities were unclear. Some staff had attended training on medication administration, but training records viewed indicated that not all staff had attended this training; in one House, only one support worker appeared to have attended this training. The Macintyre Care Personal Development Portfolio workbook included a section covering medication, with a checklist to be ticked off once completed (including assessment by the head of service); evidence of this was seen on a staff file viewed. How the home dealt with ageing and death of service users was not specifically inspected on this occasion, but from discussion during the inspection there had been some good practice in the way the home had supported some service users to deal with the death of another service user, and another service user with the death of a relative. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 15 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 The home has appropriate procedures for ensuing that service users are listened to and their concerns acted on. EVIDENCE: It was noted on previous inspections that the home’s service user guide contained a brief user-friendly version of a complaints procedure that advised service users who they could complain to (including the CSCI), informed them of how quickly their concerns would be responded to, and included the address and telephone number of the CSCI. Complaints records were viewed in one House: these were recorded in a bound Complaints Record Book, and individual blank forms were seen on individual care files. The head of service was advised to avoid any unnecessary duplication of recording, and recommended to just use one format. A few concerns had been appropriately recorded. Service users spoken to appeared confidant to express their views and feelings, where able. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 16 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 Service users live in a homely, comfortable and safe environment that is kept clean and hygienic. EVIDENCE: On the day of the inspection, each House was clean, tidy and in a safe condition. Work was in process to repair damage caused by a water leak in House 3, and each House had had a variety of improvements carried out over the year, including new kitchens in two Houses, new patio areas and fencing for two Houses, new garden fencing to the front of the property, and a number of rooms had been decorated. This had made considerable improvements to living environments, and is to be commended. The premises met the needs of current residents, were accessible to them, and provided sufficient living space. Following a burglary earlier in the year, an appropriate burglar alarm and security lights had been installed. The areas of grounds seen were tidy: the Horticultural Instructor remained responsible for maintaining the grounds as well as working with service users, but action had been taken to provide more of his time for maintenance of grounds, and for each House to be responsible for identifying and prioritising work to be done. Houses did not appear to keep a specific record of any work carried out (maintenance and refurbishment), although did maintain evidence of invoices Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 17 and of maintenance request forms. Planned maintenance and renewal programmes were discussed: one House had a House Plan for 2005-2006 covering premises issues, and Houses were developing a five-year plan for major work to be carried out. Houses carried out a monthly premises audit to check on safety and condition of the premises. Standard 30 (Hygiene and Infection Control) was not covered in detail on this inspection. It was noted that each House appeared clean and hygienic, and that few service users had any continence needs. Laundry facilities remained as previously: laundry facilities for soiled items were available in the Day Services unit (where there was also a sluice sink), and each House had a domestic washing machine for routine household (non-soiled) laundry. Laundry facilities were not inspected on this occasion. The home had a comprehensive health and safety manual, incorporating infection control information, and the registered manager was in the process of arranging for some distance learning training on infection control. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 18 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, 33, 34 and 35 The home has an effective, competent and appropriately trained staff team. However, records did not satisfactorily evidence that all staff had attended relevant training. Recruitment processes supported and protected service users, but not all information required by Regulation was satisfactorily evidenced. EVIDENCE: Rotas for the month of October were submitted with the pre-inspection questionnaire, and these showed that the home was maintaining agreed staffing levels. Staff spoken to felt that these met service user needs, and there appeared to be the flexibility to meet changes to day-to-day routines. In some instances the name of a relief/agency person covering a shift was not shown on a rota, and staff should ensure that all names are recorded. The staff team reflected the gender and cultural composition of service users, and staff were in post (and training progressing) who could communicate with a service user whose primary form of communication was through Makaton. At the time of the last inspection it had been noted that Elm House was short staffed, and was regularly using agency staff to maintain minimum staffing levels. In the rotas seen for October it appeared that Elm House continued to be regularly using agency staff and to have less flexibility of staffing than the other two Houses; however, it was noted that consistent agency staff were Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 19 attending the home and some additional hours had been agreed to support someone with challenging behaviour. Elm House staffing was discussed with the head of service, who felt that staffing had improved and that shortages in October were mainly due to staff taking annual leave. Staff are predominantly assigned to specific Houses, and it may benefit the home to review whether there are ways of sharing the expertise and skills of the staff team at times when one House is particularly short staffed, or has particular needs. The files of two new staff were viewed for evidence of recruitment practices. In one there was evidence that all the required checks (references, CRB, identification, health assessment, etc.) had been carried out prior to recruitment, although the employment history did not show the dates when previous employments had ended (making it difficult to check if there had been any gaps in employment). The second person had been working at the home through an employment agency, and then transferred to work for the home. There was no application form for this person, and therefore no employment history or criminal declaration was available. There was evidence of a photo, appropriate identification, and a health assessment. Only one new reference had been obtained by the provider; a CRB/POVA check had been obtained by the provider, but not until after the person had begun employment with them. However, there were copies of two references and a CRB/POVA check obtained by the employment agency earlier this year: this is acceptable if the person had been recruited by the employment agency and then assigned to the home, and remained working at the home when their employment transferred. Actual CRB checks were not present on the files, but there was a record of the disclosure numbers and dates, and the registered person is to make arrangements for these to be inspected. The application form contained a statement requiring the applicant to declare any criminal convictions, but no space for the person to respond to this. One file contained evidence that service users had been involved in the interview process. The pre-inspection questionnaire showed that several training courses had been attended by staff this year, and other training was planned (including first aid, fire awareness, moving and handling, and food hygiene). It also showed that out of 27 support staff, 11 had already achieved NVQ level 2 or above, and a further 9 were currently completing this. The home’s induction process incorporates a period of shadowing (confirmed by a new support worker), the completion of a Macintyre Care Personal Development Portfolio workbook (seen to cover the TOPSS specification), and also a Certificate in Working with People with a Learning Disability (former LDAF training). Individual staff training records were held in each House: those viewed showed that a number of staff had not attended training in core subjects such as fire safety, POVA, moving and handling, and medication, as well as in more specialised training such as epilepsy. Records in House 4 showed a better evidence of this training by staff, and the registered manager suggested that records in the other Houses might not be reflecting all the training completed Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 20 by staff (for example, in one House there was not yet a training record sheet in place for two new staff). This view is supported by the fact that staff consistently report that a good level of training is available to them. Staff spoken to were knowledgeable, showed a good awareness of service users’ needs, and had an appropriate attitude towards them. Staff were enthusiastic about their work, and had put thought and time into making aspects of this particularly successful (e.g. service users’ holidays). Staff in Elm House staff showed a calm approach when dealing with an episode of challenging behaviour that took place during the inspection. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 21 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 and 42 The registered manager is qualified and competent to fulfil her responsibilities. The home has systems in place to monitor whether the home is achieving its objectives, based on service users’ needs and goals. Procedures in the home promote and protect the health and safety of service users. EVIDENCE: The registered manager has completed the registered manager’s award and NVQ level 4 in care, and is also an NVQ Assessor. From discussion during the inspection it was evident that she attends other training to update knowledge and skills, with examples of training attended this year including person centred planning, supervision training and budgeting. Other heads of service were also attending relevant management training (e.g. two staff did a 5 day introduction to management course earlier in the year). Macintyre Care operates a formal quality assurance system (Investors in Care), which includes an annual audit on each house, incorporating consultation with service users. Copies of these audit reports have been Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 22 submitted to the CSCI. Macintyre Care have a service user questionnaire, but the needs of most service users at Woodacre are such that they would not be able to complete these independently, and staff therefore assist them. An alternative, more comprehensive questionnaire had been developed in Elm House to be completed by staff with or on behalf of service users: this was a good questionnaire, with sections of questions reflecting all aspects of living in the home, and there was evidence of this being completed with service users. The involvement of support staff in completing these was discussed with the head of service and the registered manager, and it was recommended that they explore whether other methods for completing these would be more objective. The head of service said that they had produced an evaluation of the feedback from this last year. In Elm House it was also noted that the House had a House Plan for 2005-2006 (this was not discussed in other Houses), with a range of aims covering premises, person centred planning, training, etc. There was no system at present for formally reviewing this as part of annual QA processes. The registered manager had also devised a questionnaire for relatives and other stakeholders (e.g. care managers, community nurses, advocates, etc.) for their views, and reported that this had been sent out this year and had provided positive feedback. The responsible individual carries out monthly monitoring visits to the home, including auditing of records, and submits reports on these to the CSCI as required under Regulation 26 of the Care Homes Regulations. Heads of service also do monthly health and safety audit reports, and the registered manager checks care plans and medication records. There was evidence that relatives had been notified of the planned inspection. Health and safety issues were only inspected in Houses 3 and 4 on this occasion. Macintyre Care produce a comprehensive health and safety information and policy file that is available to staff in each House, and incorporates relevant procedures and guidance. Both Houses maintained evidence of fire safety checks (external servicing of alarms and equipment, and internal testing of fire alarms and emergency lighting and checks on equipment), and records to show that a number of fire drills had taken place this year. Evidence of health and safety training (e.g. fire safety, moving and handling, food hygiene, etc.) did not demonstrate that all staff had attended relevant training: the registered manager believed that more staff had attended this training, but that records were not reflecting this (see previous section). Records provided evidence of appropriate servicing on electrical installation and appliances, and internal checks on hot water tap temperatures and central hot water storage temperatures. No hoists were in use in the home at this time. Evidence of fire officer and environmental health officer visits were not viewed on this inspection. Both Houses maintained a file of risk assessments: many of these covered issues related to service users, and the registered person was advised to ensure that all relevant safe working practices for staff were covered by risk assessments (e.g. use of chemicals, handling of loads, etc.). Accident records were maintained, and monitored. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 23 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 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X 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 X 14 4 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 2 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodacre Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000018000.V253953.R01.S.doc Version 5.0 Page 24 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 Standard YA17 Regulation 16(2)(i) Requirement It is required that meals are reviewed, to ensure that all individuals are receiving a suitable and sufficiently nutritious diet. This is a repeat requirement (previous timescale 31/7/05). The registered person must ensure that all staff involved in the administration of medicines have attended relevant training. Timescale for action 31/01/06 2 YA20 13 and 18 31/03/06 3 YA34 19 4 YA35 18 The registered person must 31/12/05 ensure that all records required by Regulation 19, schedule 2 (as amended 2004) are obtained for each new staff member. This includes a full employment history with written explanation of any gaps (schedule 2(6)) and details of any criminal offences (schedule 2(2) – see also recommendation 6). The home must ensure that all 31/03/06 staff have attended relevant core and service specific training, and that individual training profiles accurately reflect training attended. Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 25 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 YA6 Good Practice Recommendations The registered person should ensure that all care plans are dated, and that there is evidence that care plans have been reviewed at least every six months, with the service user (where able), and that there is evidence of the outcome of the review. It is recommended that staff receive some training in diet and nutrition. The registered person should ensure that quantities of medication carried over from previous months are clearly recorded on each new MAR sheet, so that stocks and records can be easily audited. It is recommended that each House maintain a record of any maintenance and refurbishment work carried out. It is recommended that the registered person review systems for ensuring that staff skills and experience are shared within the home at times when a particular House is short staffed or has specific challenges. Heads of service should ensure that the names of all staff working on a shift (including agency/relief staff) are clearly recorded on the rota. It is recommended that the home’s application form includes a clear section for applicants to complete to state whether they have or do not have any spent or unspent convictions. It is recommended that there is a clear record of the involvement by service users in the recruitment of new staff. It is recommended that there is a system for reviewing annual development plans, and recording whether objectives have been met. It is recommended that the registered person explore whether there are alternative ways of obtaining service users’ feedback on the service they receive. 2 3 YA17 YA20 4 5 YA24 YA31 6 7 YA31 YA34 8 9 10 YA34 YA39 YA39 Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Woodacre DS0000018000.V253953.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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