Inspection on 27/09/07 for Woodacre

This inspection was carried out on 27th September 2007.

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

The inspector 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodacre 18/10/06

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 Unannounced Inspection 27th September 2007 10:00 Woodacre DS0000018000.V351834.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.V351834.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.V351834.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 linda.pray@macintyrecharity.org 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.V351834.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 18th October 2006 Date of last inspection Brief Description of the Service: Woodacre is a residential home for up to 15 people, situated in a village location a short distance away from the town of Tiptree. The home consists of three separate Houses (referred to as Elm House, House 3 and House 4), each 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. Woodacre provides accommodation and care to people whose primary needs result from a learning disability, although some people living in the home have an additional physical disability, sensory impairment or have additional mental health needs. For people admitted since 2002, the home’s conditions of registration reflect these additional needs. Although the home primarily aims to admit younger adults (i.e. people who are under the age of 65), due to the fact that it provides a home for life, some people living there are now over the age of 65. A statement of purpose and service user guide are available at the home. Current fees are £1100 per week. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit took place at Woodacre over two days on 27th September 2007 and 3rd October, lasting ten hours. The inspection process included: discussion with the registered manager; time spent in all three Houses and discussion with each Head of Service; discussion with three staff and two service users, and time spent in the company of other service users; inspection of a sample of staff and service user records; and feedback questionnaires received from three service users, three staff and three relatives. Inspection reports also draw on any other information relating to a service that has been received by the CSCI since the service’s last inspection (e.g. complaints, protection of vulnerable adult referrals, Annual Quality Assurance Assessments, responses to previous reports, etc.). Outcomes relating to 29 Standards were inspected: there were no requirements resulting from this inspection, and 7 good practice recommendations have been made. On the day of this inspection there were 13 service users living in the home: those spoken to enjoyed living at Woodacre and were positive about the staff team. What the service does well: The home provides a friendly, family-like living environment, in premises that are homely and well maintained. It is in a location that enables people to makes good use of local community facilities, enabling people to experience a wide range of activities (e.g. shopping, swimming, cinema, meals out, etc.). The home continues to place a strong emphasis on providing a person-centred service, with attention to each person’s likes, dislikes and preferences. This is particularly evident in the way support is provided, in the wide range of activities and holidays attended by people living in the home, and in the way the home helps people to maintain contact with their families. For example, over the last year staff supported one person to visit their family who live abroad, and another person to attend a family wedding. The organisation provides staff with a good range of training, ensuring that they have the knowledge and skills to meet peoples’ needs. Staff relate well to service users, have the knowledge and skills to meet their needs, show genuine care and concern and treat them as valued individuals. Comments from relatives included: “they give X love, friendship, guidance, security and a sense of identity”, “the home is extremely good and they provide an excellent service” and “the combination of professionalism mixed with genuine warmth of feeling for the residents goes beyond a ‘job’”. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 6 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.V351834.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.V351834.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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Admission processes ensure that prospective service users’ needs are fully assessed and that they have opportunity to visit the home, enabling service users to be confidant that the home can meet their needs. EVIDENCE: No new service users have come to live in the home since the last inspection. Therefore this outcome group could not be reassessed on this occasion. However, on previous inspections it had been observed that the home has a responsible and in-depth approach to ensuring that they thoroughly assess the needs of anyone wishing to come and live at Woodacre, ensuring that staff understand what support the person will require. The home also provides prospective residents with opportunities to spend time in the home before making a decision about living there on a permanent basis. Service users and relatives consulted were confident that staff had the knowledge and skills to meet their needs. The home has a statement of purpose and a service user guide: these were not reviewed on this occasion. The Annual Quality Assurance Assessment Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 9 (AQAA) completed by the home for the Commission stated that they intend to improve these documents. This was discussed with the manager, who confirmed that these documents are still not available in a variety of formats to make them more accessible and understandable to service users, but that the organisation was intending to progress work on this. It was recommended that the home develop alternative formats of documents that provide prospective service users with information about the home. Woodacre DS0000018000.V351834.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 and 9 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service user’ plans ensure that peoples’ needs and goals are identified and appropriately met. Service users benefit from being supported to take responsible risks within their daily lives. EVIDENCE: One service user plan was inspected in each House: these plans generally covered the person’s personal, healthcare and social needs, and contained some good information about how those needs should be met, reflecting the person’s individual wishes and preferences. In one House these were particularly clear and detailed, organised in a way that meant relevant information on how to meet the person’s needs was easily accessible to staff, and had been reviewed within the last six months. A monthly review form was seen to be used, although not completed for several months: the form contained appropriate review headings, but would provide more useful Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 11 information if completed in more detail. In another House, although there was good information relating to the individual, it was difficult to easily access relevant information on how to support their daily needs, due to the way file was organised; not all the care plans had been reviewed in the last six months. There was no clear plan describing the assistance the person required with their personal care, but it was good to see that this was promptly addressed following the inspection. In the third House, the service user plan covered appropriate issues and included good information on managing challenging behaviour. Care plans were in need of reviewing, but it was good to see that the acting Head of Service had already identified this and had begun to review them. She was also hoping to produce service user plans in alternative formats for some service users. In all three Houses there was good evidence that staff supported service users to make decisions about their daily lives. Staff were able to discuss and explain how choices were offered (e.g. activities, food, holidays, etc.) and how decisions were made for people who did not have full capacity to make decisions for themselves (e.g. managing their money, buying items for them, etc.). Care plans contained information on the support people needed with money management, information on meeting personal and healthcare needs, and clear details of individual likes and dislikes. One person had regular advocacy support. Communication support was provided: care plans described how people communicated, staff had developed good signing skills with someone who was deaf, and further Makaton training had been arranged for staff. Day Services had developed pictures of different activities to help service users choose what activities they wished to attend. Risk assessments were not specifically inspected on this visit: on previous inspections it had been noted that, where relevant, files contained risk assessments relating to choices and activities, with appropriate action taken where necessary to minimise any risk. On this occasion it was noted that the home continued to be proactive and imaginative in enabling people to take reasonable risks and to be as independent as possible. For example, where a person had difficulty judging the quantity of coffee needed to make a drink, staff had implemented strategies for enabling them to make a cup of coffee that was of an appropriate strength; in another House an automatic door closure had been fitted to one bedroom door, to enable a person who used walking aids to more easily access their room independently. Strategies were in place for managing challenging behaviour, and records showed that staff monitored behaviours and mood changes. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 12 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 People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home provides a flexible lifestyle, enabling service users to engage in a wide range of activities of their choice. Local community resources are regularly accessed, and the home supports service users to maintain contact with relatives. Service users benefit from a balanced and varied diet. EVIDENCE: Woodacre continued to provide a good range of activities, both in and out of the home, providing people with both educational and leisure activities. Service users in two of the Houses were accessing college courses in the community, including media studies, fitness, and life skills. In another House, one person continued to do voluntary work in the community one day a week, supported by staff. Day Services provided a wide range of activities, including Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 13 activities that help to develop life skills (e.g. cooking): people spoke to enjoyed attending Day Services, and in each House there was a programme of regular Day Services activities attended by service users. Staff recognised the changing needs of people who were getting older: it was very clear that involvement in activities was their choice, and that daily routines were adapted to meet their needs (e.g. no early activities were arranged for a person who now needed longer to get up in the mornings). The home continues to regularly access the local community, with many opportunities for trips out (e.g. for walks, shopping, etc.) and for using community resources (churches, colleges, shops, pubs, swimming, horseriding, keep-fit class, trampolining, etc.). It was good to see one person’s care plan aiming to maintain a programme of activities outside of the home (e.g. an evening meal out each month, visiting the cinema, etc.). Another person is supported to attend a particular local church, and two service users spoke positively about going to the local village hairdresser to get their haircut. The home has its own vehicles, as its rural location limits access to public transport. Staff time is provided flexibly to enable service users to engage in activities at all times of the day and week (including evenings and weekends). The home provides a wide range of leisure activities: each House is well equipped with television and music equipment, and have comfortable indoor and outdoor space for people to use. Day services activities included crafts and relaxation, and the home also accesses the services of an aromatherapist. One person reported that they enjoyed visiting the Day Services’ ‘Coffee Bar’ each afternoon when their activities finished. Contact with relatives was encouraged and facilitated by staff, and it was good to hear that staff had supported one person to attend a family wedding, and another to visit family who lived abroad. All service users had been on holidays this year: most had had individual holidays, and they had been involved in choosing these. As mentioned above, staff had supported one person to visit family who lived abroad, and are commended for the work involved in doing this. As on previous inspections, the home promoted a strong person-centred approach, and had a very clear focus on treating every person as an individual and encouraging and facilitating individual interests and choices. Feedback from a relative regarding one person living at Woodacre stated that they had ‘gained a standard of life we did not believe was possible: they have attended college, visited cinema and pub, acquired hobbies and interests, broadened their outlook and gained life skills’. The home is commended on this. The three Houses had different systems for planning and choosing meals, but evidence in all three Houses indicated that the home continues to provide a varied and well-balanced diet, involving service users in making choices where they have the capacity to do so, or making choices on their behalf based on knowledge of their likes and dislikes. One House had been growing and eating their own vegetables this year, and is particularly commended on this. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 14 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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The support provided by staff ensures that service users personal and health care needs and preferences are well met. EVIDENCE: Most of the Service User Plans viewed clearly described how each person liked their personal support to be provided; as noted previously (reference Standard 6), in one case this information was missing but was promptly addressed after the inspection. Staff were observed to support people’s mobility needs and to encourage their independence. Arrangements were in place to ensure, where required, that support was provided by someone of the same gender. Service users were involved in their choice of key worker, and following the inspection the manager submitted a copy of a pictorial ‘wish list’ that the service intends to implement to identify what support each service user would like from staff. Healthcare needs continued to be well monitored, and staff were proactive in identifying health concerns and referring these to healthcare professionals. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 15 Records showed contact with healthcare services, and Health Action Plans were seen completed for two of the three individuals whose care plans were inspected, although one of these did not appear to have been reviewed for several years; the third person did not have a Healthcare Action plan. Over the years the home has demonstrated good support where people have developed specific healthcare needs, and supports service users to attend appointments. The home has been working in close collaboration with local learning disability services to support one client, and it was good to see that information from a conference on women’s health issues attended by staff had subsequently been shared with one of the female service users. Records showed monitoring of behaviours and moods, and also of epileptic seizures. Several service users suffer with epilepsy, and training records showed that over half of the staff had attended training in this subject in the last two years. Medication storage arrangements varied from House to House, with some medication stored centrally and some in service users’ rooms. Medication storage and records were inspected in two of the Houses: in both cases the medication was stored safely and appropriately. Most medication is dispensed to the home in a monitored dosage system, and all Medication Administration Records (MAR) are pre-printed by the pharmacist with details of each medication. In both Houses, medication received by the home was recorded, signed and dated on the MAR and there were systems in place to record any medication returned to the pharmacist. In both cases, daily medication administered was consistently recorded. However, in one House some medication details that had been handwritten on the MAR by staff had not been signed and dated by the person making the record; also some administration instructions had been altered, making it unclear how often the medication should be administered and with no cross reference to who had authorised the change. One support worker spoken to confirmed that they had completed a distance learning medication course this year. Training records showed that 15 out of 26 current staff had completed medication training, encompassing most of the senior staff responsible for medication administration. Two senior staff did not appear to have evidence of medication training, and this should be addressed. The registered manager confirmed that MAR are monitored at each shift handover to ensure they have been completed, and that this is recorded on the handover sheet. There was no specific record of any other monitoring of medication practices by Heads of Service: however, subsequent to the inspection the registered manager submitted a revised Regulation 26 report format, that included space to record the monitoring of medication practices and records in future. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 16 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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users can be confidant that staff will listen to them, and that any concerns will be acted on. Practices in the home promote the safety and protection of service users. EVIDENCE: The service’s complaints policy was not viewed on this occasion. It was noted on previous inspections that the home’s Service User Guide contained a brief user-friendly version of a complaints procedure, which advised service users who they could complain to (including the CSCI), and informed them of how quickly their concerns would be responded to. It had also been noted that the home had a pictorial version of the complaint procedure, though no other formats (e.g. audio tape, etc.). As several service users have a visual impairment, the home should explore other formats for key policies or information. All three relatives who completed surveys as part of this inspection stated that they knew how to make a complaint, and confirmed that the home has responded appropriately if they have raised any concerns. Staff understood what to do if anyone expressed concerns about the service and service users consulted knew who to speak to if they were not happy and appeared confident to speak up if they had any concerns. The CSCI has not been advised of any complaints about the service. Complaints records were viewed in two Houses: in one House there had been Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 17 no complaints made in the last year; in the other there were several appropriate records of complaints raised by service users, but no clear action and outcome had been recorded for some of these. Over the last year the home had identified two concerns in the home relating to the Safeguarding of Vulnerable Adults, and had appropriately referred these concerns to social services in accordance with local multi-agency procedures, and carried out any investigations thoroughly and professionally. In one instance there had been delay in staff reporting a concern: the organisation had identified this as incorrect practice and addressed this through staff supervision and training processes. Where a concern related to the behaviour of a resident, the registered manager was able to describe strategies and support arrangements put in place to protect other residents. Staff spoken to during the inspection knew what to do if they had concerns about the welfare or safety of residents. Training records showed that, of 26 support staff and day services staff, 21 had received training in the Protection of Vulnerable Adults (POVA), and further training was booked for this year. Service users have individual bank accounts. Systems for supporting service users to manage their monies were inspected: the home had appropriate arrangements for signatories (where service users were unable to manage their own accounts), and clear guidelines on managing service users’ monies (including for authorising expenditure). Individual records were maintained showing all monies withdrawn from individuals’ bank accounts, and any expenditure. Discussions about expenditure indicated that staff promoted service users’ best interests in the way their money was managed, and sought to enhance their quality of life through the way their money was used. Where staff felt that an individual would benefit from a particular project that incurred a significant cost, they had successfully accessed additional funding to support the person in this (e.g. for one person’s holiday abroad, and plans to convert another person’s bedroom into a bed sit). This was good to see. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 18 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, 28, 29 and 30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users’ benefit from a living environment that is homely, well maintained and safe. Bedrooms and communal space promote service users’ independence and interests. EVIDENCE: The home is located in a rural community, and one relative commented that ‘the whole ethos of the groups of small family houses provides a secure community for residents’. It is suited for its purpose and although the home does not aim to accommodate people with a physical disability, where service users have an additional physical disability, appropriate aids and adaptations have been provided to ensure that their needs are met (e.g. flashing fire alarm, consideration of the needs of people with a visual impairment, level access shower and shower seat, etc.). Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 19 At the previous inspection it was noted that there had been significant improvements to the home during the preceding eighteen months, including new kitchens and improvements to garden areas. No further major work had therefore been required in the Houses over the last year, but it was confirmed that routine maintenance had been carried out as required, and some new furniture had been obtained (e.g. new sofas in one house, some new mattresses in another). Premises were not specifically inspected on this occasion, but each House was visited and communal areas appeared warm, clean, comfortable and safe. One bedroom was viewed, and was seen to be well personalised. In another House staff had recognised that one individual liked to spend a lot of time in their room, and were progressing plans to convert their bedroom into a bed sit; this again showed the home’s attention to individual needs and lifestyles. The grounds were tidy and well-maintained: the home now employs a gardener twice a week to maintain the gardens of two of the Houses, and it was good to see that one House had been growing their own vegetables this year. 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. Training records showed that 11 of the 26 support staff and day services staff had completed infection control training this year, and a further 5 had done this training previously. On the day of the inspection the home was clean and hygienic, and free from any unpleasant odours. The registered manager confirmed that all the Houses have red bags for putting soiled laundry in, and that these are washed in a separate laundry room that is equipped with washing machines with sluice and hot wash cycles for infection control purposes, as well as a flushable sluice sink. Each House has its own domestic washing machine, and the manager confirmed that these are only used for domestic laundry. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 20 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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of 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: Staffing was specifically inspected in one House, following concerns raised in relation to extra support needed by one service user. The acting Head of Service confirmed that two staff are on duty throughout the day, and this was demonstrated in the sample rotas inspected. Additional hours are also available to provide the service user with one-to-one support at key times of the day, and the House is monitoring these additional support hours to make sure that they are used where they will most benefit the person. Although several members of staff had recently moved on from this House, it was confirmed that agency staff were used to meet any shortfalls, and that they have regular agency staff who know service users. This was confirmed with an agency carer on duty on the day of the inspection. Recruitment was in Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 21 progress to fill the vacancies. The other two Houses confirmed that they aimed to have two staff on duty throughout the day, and that staffing could be provided flexibly to meet service users’ needs. Staff consulted felt that staffing levels were sufficient to enable them to meet people’s needs. All three relatives consulted felt that the home gave service users the support and care that they expected, and considered that staff had the right skills and experience to look after people properly. Staff spoken to were knowledgeable, understood peoples’ needs, and demonstrated a person centred approach and a keen awareness of the importance of individuality. Key worker practices appeared effective, with clear roles and responsibilities. Staff communicated well with service users: where service users had limited verbal communication, staff showed a good understanding of each individual’s way of communicating. A key worker for someone who was deaf was observed to have very good signing and communication skills with that individual, and it was good to see that a two-day Makaton training course had been arranged for staff. Recruitment records were checked for two new staff, and demonstrated that all the appropriate checks had been obtained before each person started work. Evidence of CRB checks provided by Macintyre Care Head office did not confirm that a POVA (Protection of Vulnerable Adults) register check had been obtained, as recommended at the last inspection: the manager should ensure that staff records show that this check has been carried out. There was no specific evidence that service users had been involved in the recruitment of new staff: however, it was confirmed that service users spent time with prospective staff and their reactions and views were considered, and it was noted that the organisation has run workshops on ‘Inclusive Recruitment’. All staff consulted as part of this inspection reported having attended various training sessions this year, and were positive about the training provided by Macintyre Care. Staff who completed feedback questionnaires all felt that the training was relevant to their role, and helped them to understand and meet the individual needs of service users. Training provided this year included both core training (moving and handling, fire safety, etc.) and training in more specialist subjects (e.g. epilepsy, autism, etc.). A summary of staff training provided by the home showed that most staff had completed core training: although there were some gaps (e.g. some had not done training in moving and handling, POVA, fire safety, etc.), further training sessions in these subjects were booked for 2007 and early 2008. The home had clear annual training plans, showing that training updates were regularly provided. Induction processes were not specifically discussed on this inspection, but the Annual Quality Assurance Assessment (AQAA) completed by the home confirmed that their induction process meets the National Minimum Standard. The AQAA confirmed that of the 27 care staff employed at the time the AQAA was completed, 11 permanent staff and 2 bank staff had achieved NVQ level 2 or above, and a further 9 staff are working towards this. Staff were positive Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 22 about E-Learning training being provided by the organisation, but felt Internet access was needed at the home for them to fully benefit from this. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 23 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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users benefit from a well run home, and are protected by the health and safety practices in the home. EVIDENCE: Woodacre consists of three separate Houses, each with its own Head of Service; the Head of Service for House 4 is the registered manager for the home. The registered manager is appropriately trained and experienced, and has time allocated each week for responsibilities outside of her own House. Because the registered manager is not involved in the day to day running of the other two Houses, it has been agreed that she carries out the monthly Regulation 26 visits on these Houses on behalf of Macintyre Care, enabling her Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 24 to monitor practices in those Houses; the Area Manager carries out these visits in House 4. The manager had recently devised an additional form to use on her monthly monitoring visits, to enable her to evidence the records audited (e.g. service user’s monies, medication, care plans, etc.). In view of the variations noted in recording practices between the Houses (e.g. care plans, medication, etc.), it is recommended that this be implemented as part of the home’s quality assurance monitoring processes. Macintyre Care have an annual quality assurance system that involves a senior manager visiting each home, observing and assessing the quality of life and well being of people living there on that day. This had been carried out in one of the Houses earlier this year, with a report produced summarising the outcomes. The registered manager confirmed that it will also be done in the other two Houses, and that each House will receive an action plan from this. Internal auditing takes place in the form of the monthly monitoring visits referred to above, and a monthly health and safety checklist is completed in each House. Each House has its own annual ‘review and planning’ document, enabling Heads of Service to identify objectives for the year. The Annual Quality Assurance Assessment (AQAA) showed that the home is able to realistically evaluate their service, and identify areas for improvement. Although service user views are sought informally on a day-to-day basis, no formal surveys of the views of service users and other stakeholders (e.g. relatives, other professionals, etc.) have taken place in the last two years. The registered manager reported that Macintyre Care was in the process of developing new survey forms, but was not aware of when these would be available for use. The registered manager needs to establish ways of regularly seeking the views of service users and other stakeholders about the service. The Annual Quality Assurance Assessment (AQAA) completed by the home showed that the home has an appropriate range of policies and procedures, covering issues relevant to the home, and that many of these had been reviewed within the last year. The availability of key information about the home in easy read or alternative formats (e.g. audio/video tape) for service users was discussed with the manager: although the home has a pictorial complaints procedure and has recently obtained some forms in pictorial formats (e.g. a review form and a ‘wish list’ regarding support), there are still relatively few policies and procedures available in other formats to make them more accessible to service users. The manager stated that the organisation is currently working on this in relation to the Service User Guide and Statement of Purpose. It was good to see that the home had produced some information specific to individual people in other formats (e.g. a contract produced in Makaton signs for one person, and an audio tape of an agreement relating to their behaviour for another person), and the home is encouraged to progress work to develop alternative formats for other key procedures and information. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 25 The organisation has a comprehensive range of health and safety policies and procedures, and the AQAA showed that many of these had been reviewed this year. A summary of staff training showed that the home provides staff with training in relevant areas of health and safety, and the annual training plan showed that regular updates were provided. Each House follows standardised health and safety practices, and completes a monthly health and safety checklist. This is checked and signed off by the Area Manager, who also checks all accident/incident forms and collates accident statistics, which Head Office monitors. A sample of health and safety records were viewed for the Home, and seen to be up-to-date (e.g. Portable Electric Appliance testing, electrical installation certificate, checks on hot water tap temperatures, etc.). Action had been taken since the last inspection to ensure that cold-water tap temperatures and hot water central storage temperatures were regularly checked, as part of monitoring risk of Legionella within the home. The home had been inspected by the fire officer this year: the manager confirmed that the fire officer had checked the home’s fire risk assessment and was satisfied with this. Evidence of fire procedures and fire checks were sampled in one House: there was a clear fire procedure and fire safety profiles for each person living in the House, a record of regular fire drills, and records of monthly checks on fire alarms, emergency lighting, fire equipment, etc. Communal areas viewed in each House appeared safe, well maintained and free from any obvious hazards. Environmental risk assessments were not reviewed on this inspection. Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 26 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 X 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 X 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 2 3 X 3 X Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 Requirement To ensure that service users plans address each person’s current needs, all care plans must be regularly reviewed. This is a repeat requirement (last timescale 31/12/06) To ensure that service users are protected by the home’s medication administration practices, Medication Administration Records (MAR) must provide clear administration instructions for each medication. This is a repeat requirement (last timescale 30/11/06) Timescale for action 30/11/07 2. YA20 13 31/10/07 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 there is evidence that care plans have been reviewed at least every six months, with evidence of the outcome of the review. DS0000018000.V351834.R01.S.doc Version 5.2 Page 28 Woodacre It is recommended that care plans are organised in a way that enables staff to easily access information on the support each service user requires with their daily lives. 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 health action plans are completed for all service users, and regularly reviewed. Any handwritten medication details entered onto MAR forms should be clearly signed by the person entering the information. Any changes to medication administration instructions should be clear, and cross-referenced to a record of who authorised the change. The registered person should ensure that all senior staff have completed current training in the administration of medicines. Managers need to ensure that any complaints are fully recorded, showing the action taken and the outcome. Where other staff are responsible for recording a complaint, it is recommended that managers sign off the complaint to confirm it has been dealt with. The registered person is advised to ensure that evidence of CRB checks recorded on staff files also confirms that a POVA check was obtained. It is recommended that any involvement of service users in the recruitment of new staff be recorded (reference also NMS 8). 6 YA39 These are repeat recommendations. The registered person should ensure that the views of service users and other stakeholders are regularly sought as part of the home’s quality assurance processes. Where service users are unable to provide feedback independently, the service should 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). 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.) (ref also NMS 8). This is a repeat recommendation. 2. 3. YA19 YA20 4. YA22 5. YA34 7 YA40 Woodacre DS0000018000.V351834.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester 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.V351834.R01.S.doc Version 5.2 Page 30 - 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!