Inspection on 17/05/05 for Woodacre

This inspection was carried out on 17th May 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 but made no statutory requirements on the home.

Other inspections for this house

Woodacre 27/09/07

Woodacre 18/10/06

Woodacre 15/11/05

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 Tolleshunt Knights Tiptree CO5 0RR Lead Inspector Kathryn Moss Draft Report Unannounced 17th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodacre Address 38, DArcy Road, Tolleshunt Knights, Tiptree, CO5 0RR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01621 819769 01621 819078 Macintyre Care Mrs June Woods Care Home 15 Category(ies) of Learning disability 15 both registration, with number Learning disability over 65 years of age 3 of places Mental disorder, excluding learning disability or dementia 2 Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 15 persons) 2. Three 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 National Care Standards Commission 3. Two service users, under the age of 65 years, who require care by reason of a learning disability and who also have a mental disorder, whose names were made known to the Commission in April 2004 4. The total number of service users accommodated in the home not to exceed 15 persons Date of last inspection 16th November 2004 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 providing (over two floors): 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, two Houses had acting heads of service. 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 I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 17/5/05, lasting eight hours. On the day of the inspection, the service users living in House 4 were away on holiday, so there were only eight service users in residence at Woodacre: three in House 3, and five in Elm House. The inspection process included: discussions with two acting Heads of Service and four other staff; time spent observing or talking with six service users; the viewing of communal areas and one bedroom; and inspection of a sample of records. In particular, two individuals were ‘case-tracked’ to see how the home met their needs in relation to the standards. Issues relating to House 4 were not inspected on this occasion. 19 standards were covered, and 3 requirements and 7 recommendations have been made (and one previous requirement has been carried over to the next inspection as it was not inspected on this occasion). During the inspection, staff showed a very good awareness of service users’ needs and individual likes and dislikes, were caring and patient with service users, and demonstrated a positive and open attitude and approach. Service users appeared content and happy with their lives at Woodacre, relating well to staff and engaging in a variety of activities. What the service does well: What has improved since the last inspection? Significant improvements to the premises were taking place, with two new kitchens and a new patio being installed. This should greatly enhance service users’ home environment and facilities. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 6 During the inspection there was evidence that staff were reacting promptly and appropriately to some recent challenges arising from one person’s needs. Staff showed good knowledge of the strategies being implemented to monitor and deal with the situation. Since the last inspection, Woodacre’s Day Services had undergone a change in staffing and structure, and good developments were taking place in this area. 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 I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 4. By carrying out comprehensive assessments prior to new service users coming to live there, staff ensure that the home can meet their needs and aspirations. The assessment process includes opportunity for the prospective service user to visit and spend time in the home, and to have a trial period: this enables the service user to ‘test-out’ whether they want to live in the home, and to find out whether the home can meet their needs and wishes. EVIDENCE: No new service users had been admitted since the last inspection. At previous inspections it was noted that people admitted to the home in 2004 had had their needs fully assessed by Woodacre prior to admission, to ensure that the home could meet their needs. The assessment process had been very comprehensive, and included input by various relevant professionals and a planned series of visits to the home by the service user, allowing them to get to know staff and other service users before coming to live in the home. Where a service user had needs that were different to those of other people living in the home, the organisation provided staff with appropriate training (e.g. mental health training) to make sure they could meet those needs. On this inspection it was noted that staff continued to be responsive to people’s changing needs, and to react to these promptly and responsibly. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 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 standard(s) 6, 7 and 9 The home was good at responding to and meeting service users’ needs and goals. However, not all needs and goals were satisfactorily reflected in service users’ individual plans. Decision making by service users was encouraged and supported in the home. The home appropriately assesses risks, and supports service users to take reasonable risks in order to promote their independence. EVIDENCE: From discussion with the acting heads of service and with staff, it was clear that Woodacre continues to be responsive to the changing needs of service users. Individual plans are developed for each person, and one service user plan was reviewed in each of the two Houses inspected on this visit. In Elm House, the individual’s plan covered an appropriate range of personal and social needs, including challenging behaviour, etc. There was also a separate ‘Personal Support Plan’ describing how to manage challenging behaviours (not inspected on this occasion). These plans were written from the perspective of the service user, and contained good detail. There was no system for ensuring and showing that care plans are reviewed at least every 6 months. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 10 In House 3, the service user plan viewed contained some very good information about the service user and their needs, but some needs were not clearly covered (e.g. social/occupational and communication needs). Information was recorded on a variety of different formats and contained in two different care files, with some duplicated information. As most information was not dated, it was not clear which information was current; some information was out of date (e.g. college courses that were no longer attended) and needed to be archived. There was also no evidence of regular reviews. The acting head of service had some positive ideas for service user plans, and was encouraged to make this a priority for action. The home operates a link worker system: one service user spoken to was fully aware of who their link worker was, and very positive about their input. They clearly had a good relationship with their link worker, saying “I like X, she is my friend”. Decision-making about day-to-day issues and personal issues was encouraged within the home, and there were examples of staff providing service users with advice, information and choices (e.g. professional advice about dietary needs was being accessed for one person). Staff showed good awareness of different individuals’ likes and dislikes, and of how they made their choices known. They were also able to describe how decisions and choices were made for individuals who could not do this for themselves. An example for an infringement of rights for the person’s own wellbeing was clearly recorded. Risks were discussed in relation to several service users, and staff demonstrated thoughtful consideration of the issues involved, and an awareness of the need to enable service users to take responsible risks and to provide appropriate support with this (e.g. making hot drinks). Risk assessments were viewed for one service user, and covered an appropriate range of issues, although there was no evidence that all of these had been regularly reviewed. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 16 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. Daily routines were flexible, promoting service users’ right to exercise choice in their daily lives. The home offered choice of food and provided a healthy diet; however, through personal choice some individuals’ diet lacked balance and this was affecting their health. EVIDENCE: Woodacre is based in a rural, village location, and the home makes good use of the local community facilities (shops, tea rooms, etc.), and also accesses facilities in the wider community (local towns, bowling, swimming pools, etc.). Staff time was flexibly provided to support service users to attend evening activities. Daily routines were seen to be flexible: service users had choice over whether they attended activities or not, to spend time in their rooms, freedom of movement around the home and grounds, etc. Staff were observed interacting with service users, and involving them in decisions. On the day of the inspection, service users from one House were away on holiday, and holidays for individuals in other houses were being planned. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 12 For the two individuals who were case tracked during the inspection, there were good examples of staff supporting and encouraging them to pursue interests and hobbies (e.g. crafts for one person, and steam trains for another). It was also good to see staff being proactive in enabling one service user to fulfil their wish to have a pet: they had provided them with information and support to buy some goldfish, to equip a fish tank, and to learn how to care for them. An agreement with the individual had been drawn up to involve them in the responsibility for caring for the fish. Woodacre has a Day Services unit, which produces a weekly activities programme with morning, afternoon and some evening activities for each service user. For the two individuals being case tracked, the programme for the week of the inspection showed an appropriate range of activities to meet their interests and abilities (e.g. crafts, trips out, gardening, cooking; puzzles, shopping, a walk, and art). Neither service user was currently attending any college-based activities, although the link worker for one advised that they were exploring computer and drama courses. Individual care records did not show what activities had actually taken place (e.g. if the person had been on a trip, where to?), or of the outcome of each activity. An acting head of service advised that day services keep records of what activities have taken place: these were not viewed on this occasion, but it was recommended that the home ensures that there is a clear system for day services records being fed-back into regular reviews of care plans, in order to evaluate whether short or long-term individual goals are being achieved. In both Houses inspected, staff encouraged service users to choose meals on a daily basis, either as a group or individually. Meal records showed the choices made, and there was generally a good range of meals being provided; appropriate meals were being served on the day of the inspection. In Elm House the meal records did not reflect many fresh vegetables being eaten: although vegetables were provided, it appeared that many of the service users do not choose to eat these. It was recommended that staff explore other ways of serving vegetables (e.g. home made soup). One person was significantly overweight (see Personal and Healthcare Support section), which was partly due to the meal choices they made. Although it was good to see service users being offered genuine choice of food, and involved in food shopping, the need to balance choice with encouraging a healthy diet was discussed. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 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 standard(s) 18 and 19 Service users were receiving appropriate support with their personal care, resulting in personal care being well maintained. The home responds promptly to physical and emotional health needs, accessing the necessary support and advice to promote service users’ health. EVIDENCE: The service user plans viewed contained information on how service users liked their personal care to be supported. Staff spoken to had a good understanding of individual needs and preferences, and a service user spoken to was happy with the way staff supported them. The home has a link worker system, with staff and service users appropriately matched to provide continuity of support to service users. Times for providing assistance with personal care were seen to be flexible, and service users were encouraged in their individual clothing styles and preferences. Physical and emotional healthcare needs were also being well monitored and supported. Files contained evidence of support with medical appointments, and there was good evidence of relevant professionals being involved when required. For example, on the day of the inspection, the home was visited by a GP in response to someone feeling unwell, someone from a sensory team to review the outcomes of some sensory impairment training provided to staff, and another professional with regard to a service user’s challenging behaviour. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 14 Appropriate action had been taken by the home with regard to monitoring and addressing one service user’s challenging behaviour, and raising concerns with the relevant professionals. One member of staff felt that the staff team would benefit from some training on physical intervention. Staff were seeking appropriate professional dietary advice for someone who was overweight. Medication practices were not fully inspected on this occasion, and therefore the overall outcome for standard 20 was not assessed. Medication administration records (MAR) for the two service users who were being casetracked were viewed and were generally well completed. However, in both cases there were instances when medication carried over from a previous month had not been recorded (e.g. for ‘as required’ medication, where no new medication had been supplied). On one file the number of tablets for one medication had not been recorded when received by the home; on the other file some handwritten entries (e.g. medication details, or changes to instructions) had not been signed and dated by the person making the entry. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 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 standard(s) 23 The home promotes appropriate attitudes, practices and procedures to ensure the protection of service users from abuse. EVIDENCE: Policies and procedures were not reviewed on this occasion: it was noted that Macintyre Care has now reviewed all company policies, and these have been inspected on a national level by the CSCI, and considered to meet the national minimum standards. Copies of the revised policies and procedures manuals were seen to be available in the home. Previous requirements regarding the home’s complaints policy and the protection of vulnerable adults (POVA) policy are therefore now considered to be met. Staff training in the Protection of Vulnerable Adults was not discussed on this occasion. A concern raised by a service user earlier in the year had been appropriately reported and investigated by the home, the outcome of which was that no incident had occurred. On this inspection it was noted that there had been a couple of incidents where a service user had been physically aggressive towards other service users, and the need to report such incidents under POVA (and to the CSCI) was discussed with the acting heads of service. The home has clear procedures in relation to handling and managing service users’ monies. One file inspected contained clear information on the person’s financial arrangements, their property was recorded, and there was evidence of correspondence on their behalf in relation to financial matters. Service users had individual bank accounts. Cash held by the home on service users’ behalf was stored securely, and clearly recorded. Records and monies were inspected for one service user, and seen to balance. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 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 standard(s) 24 Woodacre promotes a homely, comfortable and safe environment. EVIDENCE: Woodacre’s premises are suitable to its purpose and meet service users’ needs. Although premises issues were not inspected in detail on this occasion, areas of the home that were viewed were safe and well-maintained, homely, clean and tidy; rooms were appropriately personalised. It was noted that several improvements to the home had taken place or were in progress, including the fitting of new kitchens in Elm House and House 4, a new patio to the rear of House 3, and new fencing to the right hand boundary. Decoration was required in House 3 to address some water damage, once areas affected have fully dried out. On the day of the inspection it was observed that some areas of the grounds appeared untidy (e.g. to the front of the property and beside the driveway): no additional support with garden maintenance had been provided since the last inspection, and the Horticultural Instructor still remained responsible for maintaining the grounds as well as working with service users. On the day of the inspection there was evidence of grass being cut, and a vegetable plot had been prepared and sown. Appropriate security arrangements were being progressed, following a recent burglary. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Service users were generally being effectively supported by a flexible and appropriately trained staff team. EVIDENCE: Standard 33 was only partly inspected on this occasion. Staffing reflected the gender mix of service users, and staff were of an appropriate age to provide for service users’ needs. Staffing was flexible, to meet service users’ needs (e.g. to go out in the evenings). From discussion with staff, the organisation continues to provide a good range of training for staff, and specialist support had been accessed from outside agencies where required (e.g. with challenging behaviour, and sensory impairment). It was noted that Elm House was currently short staffed, and therefore dependent on agency staff and cover from the other Houses. This was difficult at a time when the dynamics and demands of service users needed a consistent staff team. However, it was good to see that regular agency support workers were used, and that the particular needs of Elm House were being prioritised. On the afternoon of the inspection, only the acting head of service was on duty in House 3 as the other staff member was covering in Elm House. The acting head of service stated that as they only had three service users in residence (one of whom was in Day Services), one staff member was sufficient on that occasion. This should be monitored. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40 and 41 The home had an appropriate range of policies and procedures in place to protect service users’ rights and best interests. However, some record keeping did not satisfactorily reflect this. EVIDENCE: It was noted that Macintyre Care has now reviewed all company policies relating to staff employment and service user care; copies of the revised policies and procedures manuals were seen to be available in the home. The content of these policies and procedures was not reviewed on this occasion, as these had been inspected on a national level by the CSCI, and considered to meet the national minimum standards. The involvement of service users in reviewing policies and procedures, and the provision of these documents in formats accessible to them, was not discussed on this occasion. Not all areas of record keeping were reviewed on this occasion, but some areas did require some further action (e.g. care plans and medication records). Regulation 37 notices were discussed with both acting heads of service, who Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 19 were reminded of the need to submit these to the CSCI with respect to any events in the home that adversely affect the well-being or safety of service. This was particularly in relation to incidents of aggression by one service user (especially where an injury resulted), and to a flood in House 3 that required service users to be vacated during the night. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 20 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 3 3 x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 x 3 2 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME 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 x x x 3 2 x x I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 15 Requirement Timescale for action 31/8/05 2. 17 16(2)(i) 3. 41 37 4. 42 23 and 13 Individual Service User Plans must cover all aspects of personal and social support, and be reviewed regularly. It is required that meals are 31/7/05 reviewed, to ensure that all individuals are receiving a suitable and sufficiently nutritious diet. It is required that Regulation 37 30/6/05 notices are submitted to the CSCI in relation to any events listed under this Regulation. 30/6/05 The registered person must ensure that the routine testing of fire alarms is clearly recorded. The registered person must ensure that evidence of fire drills includes the names of the staff attending them. These requirements are carried over from the previous report, as they were not inspected on this occasion. They will be reviewed on the next inspection. Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 6 9 12 Good Practice Recommendations Individual Service User Plans should be dated and be reviewed at least every six months (with the service user, where able). It is recommended that risk assessments are regularly reviewed, updated where required. It is recommended that a clear record of activities and daily occupation is maintained as part of service users daily records, and that this information is used to evaluate the effectiveness of their individual plans. It is recommended that staff receive training in diet and nutrition. It is recommended that staff receive training in physical intervention. The registered person should ensure that medication administration records clearly show the quantity of any medication carried over from a previous month, and that any amendments to medication details or instructions are signed and dated by the person making the record. It is recommended that registered person review whether the home has sufficient staffing to maintain the grounds to a satisfactory level. 4. 5. 6. 17 19 and 23 20 7. 24 Woodacre I56-I05 s18000 Woodacre v227834 170505 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Fairfax House Causton Road Colchester 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. 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