Inspection on 18/10/06 for Woodacre

This inspection was carried out on 18th October 2006.

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 no outstanding requirements from the previous inspection report, but 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 15/11/05

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 Key Unannounced Inspection 18th October 2006 10:00 Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 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), Physical disability (1) Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 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 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 One person under the age of 65 years who requires care by reason of a learning disability and who also has a physical disability, whose name was provided to the Commission in May 2006 The total number of service users accommodated in the home must not exceed 15 persons 15th November 2005 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 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. Woodacre is run by Macintyre Care, and the property is leased from the area health authority. Each house has a head of service, and the head of service for House 4 is the registered manager on behalf of the overall home. There are dedicated day services staff employed at Woodacre. Woodacre provides accommodation and care to service users whose primary needs result from a learning disability, although some service users who were living in the home prior to April 2002 have an additional physical disability or sensory impairment. The home’s conditions of registration reflect service users admitted to the home since April 2002 with additional mental health needs or needs arising from a physical disability. Although the home is primarily registered for adults under the age of 65 who have a learning disability (LD), due to the fact that the home aims to be a home for life two 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 homes conditions of registration. A statement of purpose and service user guide are available at the home. Current fees at the home range from £44,000 to £53,000 per year. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 18th October 2006, with and a return visit on the 20th October because some management staff were not present on the first day. Due to the particular structure of the home (see Description of Service), not every standard could be inspected in each House. Although it is noted that there are differences in practices between the Houses, for the purpose of this report observations in any one House are considered to apply to the whole home for the purpose of any resulting requirements or recommendations. The inspection process included: • • • • • • Discussions with all three Heads of Service (including the registered manager); Discussions with two support staff, one senior support staff, and the Day Services co-ordinator; Discussions with one resident in each House, and time spent with or observing other residents. A brief inspection of the premises, including the laundry, communal areas, day services, and one service user’s bedroom; Inspection of a sample of records; Feedback from 4 relatives through postal questionnaires 30 Standards were covered, and 4 requirements and 9 recommendations have been made. On the day of this inspection, the home was maintained in a good condition. There were 13 service users living in the home: service users were receiving good care and support, and those spoken to enjoyed living at Woodacre and were positive about the staff team. What the service does well: The home has a strong emphasis on providing a person-centred service, with attention paid to providing support and activities in a way that meets individual choices. This was particularly evident through the wide range of individual holidays that service users had been on this year, and the range of daily activities available both on-site and away from the home. Service users seen appeared happy and content, and those spoken to were positive about their lives at Woodacre. Staff related well to service users, and showed an interest in and commitment to their work. Key workers showed good knowledge of service users’ needs, and those spoken to were clearly looking out for the service user’s best interests. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 6 Relatives who provided feedback were happy with the care provided at Woodacre, and all felt that they were made welcome when they visited the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 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.V316973.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission processes ensure that prospective service users’ needs are assessed and that the person has opportunity to visit the home, enabling both staff and service users to be confidant that the home can meet their needs. EVIDENCE: Only one new service user had been admitted to the home in the last year, and their file showed comprehensive pre-admission assessment information obtained by the home prior to their admission. This, together with visits to see the service user and visits to the home by the service user, had enabled the home to be confidant that it could meet the person’s needs. The home had its own assessment form: this had not been fully completed, and although ample information about the person was provided on the other records obtained, it is recommended that the home’s assessment form be completed for new service users as it provided a good format for summarising all the information in one place. Various information was stored in several files and a box file, and it was recommended that all current information be filed in a place that is easily accessible to staff, and that other information is archived. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 9 The registered manager had discussed the new person’s needs with the CSCI prior to their admission, having identified that the person had needs (a physical disability) that fell outside of the home’s current registration. The registered manager applied for a variation to the home’s registration, and demonstrated at that time that the home had the facilities and skills to meet the person’s needs. There had been a clear process leading up to this person’s admission to the home, where staff had met the person and the individual had made several visits to the home to be able to see for themselves whether they felt it would meet their needs. The person was spoken to during the inspection and was very positive about their experience of coming to live at Woodacre, was happy there, and felt they had been made welcome and received suitable support. Issues around meeting the person’s physical needs were inspected on this visit: care plans reflected that their needs were understood by staff, appropriate equipment was in place to promote independence, and advice had been sought from Occupational Therapists and Physiotherapists. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs and goals were reflected in their individual plans, and the home promotes a person centred approach to care planning. Decision making by service users is supported in the home, and service users are encouraged to participate in day-to-day decisions within the home. Service users are supported to take responsible risks within their daily lives. EVIDENCE: One person’s care plan was inspected in each House: each care plan covered the person’s personal, healthcare and social needs, and contained some very good information about how those needs should be met, including the person’s wishes and preferences. In one instance the file was not well organised, with no evidence that care plans had been reviewed in the previous two years. This needed to be addressed. In another instance not all information had been clearly dated, and where there was more than one Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 11 version of some information (e.g. guidance relating to catheter care), it was difficult to ascertain which was the most recent guidance. It is recommended that Heads of Service ensure that all documents are dated, and that only one version of each care plan or guidance is maintained on the working files. The file of a new service user did not contain evidence to show whether the person had been involved in the development of their care plans, and staff should explore ways of doing this. Throughout the inspection there were examples of service users being encouraged and supported to exercise choice and control over their lives (e.g. meals, activities, daily routines, what to wear, etc.). Staff were able to describe how service users were supported to buy new clothes, personalise their rooms, and follow their interests. Care plans detailed their likes and dislikes, and through this showed how some choices were made for service users who were unable to make choices for themselves. Staff provided appropriate information to help service users make decisions (e.g. options for holidays and activities, healthcare advice, etc.), and there were staff in the home with the communication skills to support specific service users (e.g. Makaton). Some service users’ files viewed contained clear risk assessments relating to their choices and activities, and appropriate action taken where necessary (e.g. in one House a small kettle had been bought to minimise the risk for one service user when making themselves a hot drink). Service users had their own bank accounts and were supported (where able) to manage their money (e.g. going to the bank to withdraw money; keeping their own money in their room, etc.). Where necessary staff advise service users regarding spending their money, and support them to make purchases and choices. Service users were encouraged to keep to a weekly budget in order to save some money for larger costs (e.g. holidays). Where service users lacked understanding of money, a staff member spoken to was able to describe how they made decisions on their behalf, weighing up the service user’s interests and needs and aiming to promote their quality of life through the way their money was spent. One service user’s care plan reflected their aim to work towards increasing their independence in managing their own money. Within the home, service users are consulted on day-to-day choices on aspects of life in the home (e.g. in one House, service users had chosen new chairs for the lounge). There was also good day-to-day communication with service users throughout the home and service user meetings were held in two houses: one person particularly commented on how they enjoyed this opportunity to meet and make suggestions. Where a service user had specific communication needs because they were deaf (and used Makaton signs), a staff member in the House had developed specialist skills in this area. Few service users had the capacity to contribute meaningful in management issues, and although the home encouraged service users to meet and talk with new staff applicants, further work needed to be done to Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 12 involve service users more actively in staff recruitment interviews (e.g. recording their feedback, etc.). The home has a simple pictorial version of the complaints procedure, and the registered manager confirmed that a video format was also available, and also a video on abuse awareness and reporting. The manager reported that a service user agreement has been produced in a Makaton (picture) format for one service user, and they intend to produce a version of their service user feedback questionnaire in this format. However, the home does not yet have a range of other policies and procedures available in different formats to suit service users’ abilities. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a flexible lifestyle, enabling service users to engage in activities of their choice, and promoting a person-centred approach. Local community resources are regularly accessed, and the home supports service users to maintain contact with relatives. Good action had been taken to promote a healthy diet within the home. EVIDENCE: No service users at Woodacre are currently able to engage in paid employment, but one person has been successfully engaged in some voluntary work for some time now, and was clearly enjoying this. It was noted that the home had recently experienced difficulty accessing college courses for service users, as many courses had been cancelled due to lack of numbers (possibly resulting from an increase in the fees being Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 14 charged). Nevertheless, several service users were attending college classes (e.g. computers, ‘trip down memory lane’, ‘dance crazy’, etc.), and the onsite Day Services provided opportunities for other educational and developmental activities (e.g. numeracy and literacy, use of computers, cooking skills, etc.). The needs of current service users at Woodacre are such that most have limited capacity to fully participate in community life (e.g. in relation to being politically active, voting, etc.). However, the home makes good use of community resources, and tries to include service users as fully as possible in the local community. The home uses local supermarkets and involves service users in the weekly shopping, and service users use the local library, shops and pubs, and also facilities in the wider community (e.g. cinema, swimming pool, churches, etc.). In each of the three Houses, service users were supported to do a wide range of activities both in and out of the home. As well as college classes, service users were able to follow other interests (e.g. trampolining, horse-riding, swimming, etc.), and there were regular opportunities to go shopping and to engage in other leisure activities (e.g. trips to the cinema). Staffing was provided flexibly to enable evening activities (e.g. some people were due to attend a local Brass Band ‘Swing’ event at the weekend, another person had recently been taken to a barn dance, some attended an evening Club, etc.). The home also has a separate ‘Day Services’ unit that provides a range of on-site activities, both leisure activities (crafts, relaxation, beauty therapy, etc.) and activities for personal development (facilities for cooking, using computers, reading and writing, etc.). The Day Services unit includes a coffee bar that is used at break times and at the end of the afternoon, as well as for social events. It was noted that the Day Services unit was being well used by service users (e.g. on one morning during the inspection, seven service users were engaged in four separate activities). Service users had all had opportunity to go on holiday this year. Holidays were individual, varied, and were the person’s own choice (where able). Examples included staying in a cottage in Norfolk, going to Holiday Camps (e.g. Butlins), a trip to Bristol to see relatives, a trip to the Isle of Wight, and a camp on Mersea Island. Some service users had been away more than once: for example, a staff member was taking one person away for a night at the time of this inspection, and another person had a short break planned for December. During the inspection a Head of Service was observed to respond positively to a service user’s request to go away on another short break, showing a flexible, responsive and individual approach by the home. Service users in the home had very diverse needs as a result of age, specific disabilities (e.g. some have additional sensory impairment or physical disabilities), spiritual needs and personal preferences. The home had a person centred approach to meeting these, with a younger person being Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 15 helped to engage in their particular interests (e.g. horse riding and trampolining) whilst an older person’s preferences for quiet, individual time were respected (support to do rug making, time spent relaxing in the Snoozelem room, etc.). There was good evidence of individual interests being encouraged and supported, including attending church. The home supports service users to maintain links with family and friends, service users can chose to have visitors or not, and space is available (e.g. Day Services) if service users wish to meet with family in private. Staff supported service users to keep in contact with family, through visiting and through telephone calls. Last year the home took one service user to visit family who lived abroad and this year another was taken to visit relatives in the UK. All four relatives who provided feedback as part of this inspection stated that the home kept them informed of important matters affecting the service user, that staff welcomed them in the home at any time, and that there was somewhere that they could meet with the service user in private. One relative stated: “I’m always made to feel part of the family and my visits are always enjoyable”. Through social events and use of the Day Services, service users are encouraged to mix with each other across the Houses. Daily routines in the Houses were flexible. Service users were involved in household tasks, although the level of responsibility was not clearly detailed in the care plans viewed. Staff treated service users in a way that respected their rights as individuals, interacting with them, respecting their choices, and giving them unrestricted access to communal areas of the home. Only one service user’s bedroom was viewed on this occasion, but this room was well personalised, and contained furnishings and possessions that reflected the person’s interests and choices, including a TV and music system. They had recently bought a new desk, and were clearly very pleased with this. At the last inspection, it was identified that the home needed to review the balance of meals being provided to some service users, as although choice was being actively promoted, not all service users’ choices provided them with a suitably balanced diet. On this visit, records showed a significantly better range of meals and vegetables being eaten, and noticeable weight loss had been achieved for several service users as a result of reviewing and monitoring food. One House had developed a scrapbook of food pictures (including pictures of ‘healthy’ foods) and were using this to involve Service Users in planning weekly menus, and had also devised a shopping list with Makaton pictures alongside items to promote service users’ involvement in shopping. They had been making fruit ‘smoothies’ and soups to encourage service users to eat more fruit and vegetables. The home had had a healthy eating club, and one person had briefly attended Weight Watchers. Weights were being monitored, and the input of a dietician had been sought for another person, who had lost weight as a result of staff monitoring the variety and balance of meals being served. A staff member from each House Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 16 was due to start a distance learning nutrition course. Staff are commended for the positive action taken to address dietary needs in the home. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users were receiving appropriate support with their personal care, resulting in personal care being well maintained. The home provided support to meet physical and emotional health needs, accessing the necessary medical support and advice to promote service users’ health. Although some areas for improvement were identified relating to medication records, based on past evidence the CSCI is confident that the provider will take action to manage the improvements required. EVIDENCE: Three care files were sampled (one in each House), and each recorded service users’ likes and dislikes, methods of communication, preferred routines for personal care, etc. Evidence showed that the home promoted a person centred approach, endeavouring to provide support in the way the person preferred. Times for personal care, getting up and going to bed, etc., were seen to be flexible; service users were encouraged to choose what to wear and how to spend their day. The home operates a link (key) worker system, and Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 18 service users confirmed that they had some choice of the staff allocated to them, including staff of the same gender if they wished; those spoken to felt they got on well with their link worker. Independence was encouraged through care plans, consistent ways of working with service users, and the use of aids and equipment where required. One Head of Service provided good examples of ways in which they expected staff to promote service users’ dignity and respect, including giving service users control over their environment (e.g. service users being able to choose new communal furniture and make decisions about their living environment), and ensuring that service users were dressed properly, appropriate to their age, and in a manner which ensured that they were protected from making themselves vulnerable (e.g. clothes that fitted properly and did not expose them). Files contained good information on the action required to support healthcare needs, and clear records of healthcare appointments and the outcomes. In one House it was noted that Health Action Plans were being implemented, and there was evidence to show that staff had accessed appropriate medical support promptly when required, as well as arranging routine health checks. Meal records showed that service users were being provided with a balanced diet, and also reflected specific dietary needs. Additional records were maintained to reflect care needs and daily activities, including the monitoring of any challenging behaviours. Staff were appropriately monitoring other health care needs where required (e.g. blood sugar levels, etc.). In one instance where staff were testing a person’s urine for risk of urine infections, the care plan described how this should be done but did not include guidance on how to interpret results; it was recommended that this be added. The home’s medication policy was not inspected on this occasion. Medication issues were only inspected in House 3: in this House medication stocks were kept individually in locked cabinets in service users’ rooms (not viewed); medication was dispensed to the home in a monitored dosage system. The pharmacist provided pre-printed medication administration records (MAR): records sampled for one person showed that medication administered had been consistently recorded by staff; the recording of medication received by the home was not inspected on this occasion. The person’s medications were discussed with the Head of Service: this highlighted the need to ensure that staff are aware of what each medication is for, and of any possible side effects. In this instance there was no information (e.g. a medication profile) easily available to staff relating to this, although an example was seen on another person’s file. It was noted that one medication prescribed when the person was admitted to the home did not appear to be shown on the current MAR sheet: although the person now rarely used this, the Head of Service was not aware of the GP having discontinued the medication. They were therefore advised to find out why this was not longer listed and to ensure that all prescribed medication is recorded on the MAR. On a previous MAR sheet, the administration Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 19 instructions for this medication were ‘as guidelines’, but no guidelines were available. The Head of Service stated that these were with the initial information provided when the person was admitted, and was advised to ensure that all administration instructions (or where they are to be found) are clearly recorded on the MAR. No service users currently self-medicate: for those who have capacity, the home is recommended to explore options for service users to take more control over the administration of their medicines. The registered manager stated that eight staff had completed a distance learning course in medication administration last year, and a further four staff are due to do this training. She stated that the home has an in-house medication assessment form included in the Personal Development Plan pack completed by new staff when they start, and that the home had just received a training pack on the use of the monitored dosage system. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has appropriate procedures for ensuing that service users are listened to and their concerns acted on, and for promoting the safety and protection of service users. EVIDENCE: The service’s complaints policy was not viewed on this occasion: on previous inspections it had been noted 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. It had also been noted that the home had a pictorial version of the complaint procedure. None of the relatives consulted as part of this inspection were aware of the home’s complaints procedure, and it is recommended that relatives be provided with this information. Complaints records were viewed in one House, and showed four complaints recorded this year: clear action had been recorded for most of these, but one appeared not to have been addressed. The head of service was not aware that a staff member had recorded this, and was advised to ensure that staff recording complaints always refer these to the head of service. The records reflected appropriate concerns being recorded. Service users spoken to appeared confidant to express their views and feelings, and had good Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 21 relationships with link workers and their Head of Service. No complaints have been received by the CSCI, and none of the relatives consulted had had any cause to make a complaint to the home. Macintyre Care policies and procedures for the Protection of Vulnerable Adults (POVA) were not viewed on this occasion, but had been previously reviewed by the CSCI and considered to meet the minimum standards. A concern raised earlier in the year, whilst judged not to constitute a POVA, had been appropriately identified and responded to well by the home. Training records viewed in two Houses showed that most staff had attended POVA training, and the inspector was advised that several staff had attended POVA workshops this year. One staff member had been in post a year but did not yet have evidence of POVA training; however, that this subject was covered as part of the Macintyre Care induction (Personal Development Plan). Where money was looked after on behalf of service users, there were safe systems in place for this (including clear records kept). It was good to see some care plans or risk assessments specifically addressing the issue of protecting service users (e.g. re lack of money awareness and financial vulnerability, risk of sexual abuse in relation to wearing appropriate clothing and ensuring the person remained suitably covered, etc.). In one House there was a good pictorial sign on front door re checking who was visiting before opening door. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment that is well maintained and kept clean and hygienic. Bedrooms and communal space promote service users’ independence, and aids and adaptations are provided where required. EVIDENCE: Each House appeared warm, comfortable and safe; it was confirmed that repairs were carried out promptly when needed, and that there were systems in place to meet maintenance needs. Communal areas were clean and tidy, and well used; it was noted that there were new TVs in each House, and it was good to see a computer available for service users to use in Elm House lounge. Day Services included additional communal space that could be used by service users, including at weekends. Areas of the premises inspected were well maintained: there had been significant areas of improvement over the last Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 23 eighteen months, including new kitchens and the development of the grounds (e.g. new patios behind two of the Houses). The Head of Service for House 4 stated that they were now maintaining records of repairs and refurbishment carried out (not viewed on this occasion). All service users had single rooms that offered sufficient space for their needs. No bedrooms have ensuite toilets. Where service users had needs resulting from an additional physical or sensory impairment, the home had accessed appropriate aids and adaptations to promote their independence, and Occupational Therapy advice had been sought where required. For one person who was deaf, the House had installed a flashing fire alarm in the corridor and in the person’s room. Another House had an assisted bathroom with a bath hoist and also a level access shower, and had obtained a shower seat for a new service user. Staff showed good awareness of the needs of service users who have a visual impairment, who were observed to manage independently within the Home environment. The home has comprehensive health and safety policies and guidance, including information relating to infection control; personal protective equipment (disposable gloves and aprons) are available to staff. On the day of the inspection the home was clean and hygienic, and free from any unpleasant odours. Each House had domestic washing machines in kitchen or conservatory areas, and the home has separate laundry facilities in the Day Services for any soiled items. Washing machines in this laundry area had the capacity for sluice and hot wash cycles for infection control purposes, and the area also contained a flushable sluice sink and second sink. Ten staff were due to start a distance learning infection control course. All four relatives who provided feedback as part of this inspection stated that the premises were usually clean, warm and well maintained when they visited the home. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective, competent and appropriately trained staff team, with sufficient staff on duty to meet service users’ needs. Recruitment processes supported and protected service users. EVIDENCE: Recruitment records were viewed for two staff recruited since the last inspection. Both files contained a completed application form with the person’s employment history, although in one case this contained little information on how the person had spent their time during a break in employment. Both files contained written references received before the person started work, evidence of health check, evidence of Identity and photos, and evidence of a Criminal Records Bureau (CRB) check in the form of a memo from Macintyre Care detailing the date and the disclosure number. This did not specify that a POVA check had been included in the CRB check, and the manager was advised to ensure that there is evidence on file to confirm this. One of the CRB checks had not been received before the person had started work, but there was Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 25 evidence that a POVAfirst check had been obtained. There had been little recent use of agency staff, but the registered manager confirmed that when agency staff are used the home is able to access regular agency staff who know the home. The home was maintaining staffing levels appropriate to the number and needs of the service users living in the home, and which enabled varied and flexible daily routines. Rotas viewed in one House showed that staffing levels were being consistently maintained; Day Services staff provided additional support during the day, facilitating one-to-one and group work with service users. Shift patterns enabled continuity throughout the day, with usually one person in each house working a long day. The Houses were aware of when any particular service user required someone of the same gender to support them and made provision for this, with staff from other Houses assisting at specific times if required. The home was able to provide additional staff for specific activities (e.g. to take someone out in the evening). Staff spoken to felt that staffing levels enabled them to meet peoples’ needs, and all four relatives consulted felt that there were always sufficient numbers of staff on duty. Staff showed good knowledge of the service users in their Houses, appropriate attitude, skills and experience, and demonstrated a personcentred approach. Of the 24 care staff currently working in the home (eight in each house), 12 had already achieved NVQ level 2 or above (i.e. 50 ), and a further six were working towards this qualification. Induction training for new staff was not specifically inspected on this occasion, although files viewed for two new staff showed evidence that a LDAF (Learning Disability Award Framework) induction and foundation training was underway. An annual training plan seen in one House showed that the team’s annual training needs had been identified; the registered manager co-ordinates key training for the home. Each House maintained individual training records (viewed in Elm House and House 4): a training summary seen in Elm House indicated that some staff had not received training in fire safety, food hygiene, infection control, epilepsy and first aid; individual training records in House 4 showed that most staff had done all key training, but one person had no record of moving and handling, epilepsy or POVA training. However, the registered manager advised that there had been some recent training that may not have yet been recorded (including food hygiene, moving and handling, POVA, and first aid), and confirmed that further training had been booked in fire safety, moving and handling, epilepsy, medication, nutrition and infection control. In addition to key training, records showed that training in a relevant range of other subjects had been attended by staff this year, including: mental health awareness, autism, care planning, bereavement, and epilepsy. Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Although action was required relating to systems for monitoring risk of Legionella in the home, based on past evidence the CSCI is confidant that the provider will take action to manage the improvement required. EVIDENCE: The registered manager is appropriately trained and experienced. Although also the Head of Service for House 4, she has time allocated each week for Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 27 responsibilities outside of that House; because she is not involved in the dayto-day running of the other two Houses, she carries out monthly (Regulation 26) monitoring visits to these Houses, with any issues identified being followed up by the Area Manager (who completes Regulation 26 monitoring visits to House 4). Staff spoken to felt the home was well managed, and all confirmed that they felt well supported. Regular staff meetings took place, and staff had opportunity to contribute to the running of the home (e.g. a recent staff survey had been carried out about the role of the Day Services). Macintyre Care operates a formal quality assurance system (‘Investors in Care’) to ensure that the home is run in the best interests of service users, and to monitor the quality of the service. This includes an annual audit on each house, incorporating consultation with service users; from this audit the area manager compiles a report and action plan. Although the provider has a questionnaire for obtaining service users’ feedback, because of the limited abilities of some of the service users to express their views, an alternative questionnaire had been developed by one of the Heads of Service. This had been completed by staff with or on behalf of service users in Elm House in November 2005: it contained a good range of questions, and there was evidence of an action plan resulting from the survey. The Head of Service was aware that it may not be appropriate for support staff to be completing these questionnaires with service users, and was considering other ways of facilitating this feedback in future. The Head of Service for Elm House also confirmed that they had an annual development plan for the home (not viewed) that had been developed with the involvement of the staff team, and was reminded of the need to implement systems for periodically reviewing action plans to see if aims have been achieved. Health and safety records were viewed in two of the Houses: not all records were inspected, but from those seen it appeared that the home was maintaining appropriate checks on health and safety issues (e.g. checks on fire alarms and emergency lighting, testing of hot tap water and bath temperatures, monthly health and safety checklists completed in each House, etc.). Accident records were viewed in one House, and risk assessments were seen completed in another House. However, in both Houses it was noted that, although the organisation had a policy relating to prevention of Legionella, there were no specific systems in operation to monitor risk of Legionella (e.g. there was no monitoring of cold and hot water storage temperatures). Action is therefore needed to address this. The organisation has an extensive health and safety procedures file, and provides staff with training in relevant areas of health and safety. Not all staff training records were viewed: from those seen it appeared that some staff lacked evidence of current training in some areas of health and safety (e.g. fire safety, moving and handling, etc.). However, the Registered Manager advised that further training in these areas was due and had been booked (see previous section). Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA6 YA20 Regulation 15 13 Requirement Timescale for action 31/12/06 3 YA20 13 4 YA42 13 The registered person must ensure that all care plans are regularly reviewed. The registered person must 30/11/06 ensure that Medication Administration Records (MAR) provide clear administration instructions for each medication (or show where this is recorded). The registered person must 30/11/06 ensure all prescribed medication is recorded on the Medication Administration Record. The registered person must 30/11/06 ensure that there are systems in operation in the home to monitor and control the risk of Legionella Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 30 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 evidence of the outcome of the review. This is a repeat recommendation. It is recommended that the service develop ways of evidencing service users’ involvement in the development and review of their care plans It is recommended that the service progress action to make relevant information and policies available in alternative formats that are more accessible to service users (e.g. pictorial, video, audio, etc.). It is recommended that service users’ involvement in household tasks be specified in their individual plans. It is recommended that there is a clear record of the involvement by service users in the recruitment of new staff. This is a repeat recommendation (reference also NMS 34). The registered person should ensure that all staff are aware of the general purpose of each service user’s medications, and of any possible side effects. It is recommended that clear medication profiles be developed for each person, showing the type, purpose and side effects of any medication. The registered person is advised to ensure that evidence of CRB checks recorded on staff files also confirms that a POVA check was obtained. The registered person should ensure that any gaps in a prospective staff member’s employment history are fully explored and a written explanation recorded. The registered person should monitor and ensure that all staff are up to date in all key areas of training, especially health and safety, POVA and any specific topics relating to service users (e.g. epilepsy). 2. YA8 3. 4. YA16 YA18 5. YA20 6. 7. 8. YA34 YA34 YA35 Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 31 9. YA39 10. YA39 It is recommended that there is a system for reviewing annual development plans, and recording whether objectives have been met. This is a repeat recommendation. It is recommended that the registered person explore whether there are alternative ways of obtaining service users’ feedback on the service they receive (i.e. that do not involve the staff responsible for delivering the service completing questionnaires on their behalf). Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodacre DS0000018000.V316973.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!