Inspection on 12/10/07 for Woodcrofts

This inspection was carried out on 12th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodcrofts 07/04/10

Woodcrofts 30/09/08

Woodcrofts 23/03/06

Woodcrofts 30/09/05

Woodcrofts 06/12/04

Woodcrofts 30/07/04

Woodcrofts 20/02/04

Woodcrofts 20/10/03

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOME ADULTS 18-65 Woodcrofts 164 Warrington Road Widnes Cheshire WA8 0AT Lead Inspector Paul Ramsden Unannounced Inspection 12th October 2007 10:50 Woodcrofts DS0000005202.V339428.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 Woodcrofts DS0000005202.V339428.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. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodcrofts Address 164 Warrington Road Widnes Cheshire WA8 0AT 0151 424 5347 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) Woodcrofts Residential Homes Limited. Mrs Margaret May Lyons Mr Terence Lyons Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (7) Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 21 service users to include:* 21 of the Service Users may be MD * 7 of the Service Users may be MD(E) Date of last inspection 7th September 2006 Brief Description of the Service: Woodcrofts is a privately owned two-storey care home providing accommodation to 21 adults with mental health needs. Three members of the family, one of which lives on the premises, share the day-to-day management responsibilities. The home is located approximately three-quarters of a mile from Widnes town centre and is close to a church, shops and other community facilities. There are adequate car parking facilities available adjacent to the home. Residents’ accommodation consists of seventeen single and two double bedrooms [used as single accommodation]. There are a variety of communal facilities available. These include three lounges, one of which is the designated smoking area and a dining room. Woodcrofts has an adequate number of toilets and bathrooms available for residents. The current fees for the home are £360 per week. Further details regarding fees are available from the proprietor. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on the 12 October 2007 and lasted 6 hours and 15 minutes. Paul Ramsden, Inspector, undertook the visit. All of the key standards for young adults were looked at. This visit was just one part of the inspection. Before the visit the home manager was also asked to complete an Annual Quality Assurance Assessment [AQAA] in order to provide up to date information about services in the home. Questionnaires were handed to residents and staff members during the visit in order to find out their views about the quality of the service. Other information received since the last key inspection was also reviewed. Two resident survey forms were returned during the inspection. During the visit various records and the premises were looked at. A number of residents and staff members were spoken with; they gave their views about the home and the service provided. What the service does well: What has improved since the last inspection? During a discussion with the deputy manager he considered that the home has maintained the link with the local psychiatric service and more emphasis is now placed upon preventative intervention rather than that provided following a crisis. Improvements to the physical standards within the home have been made; this includes the decoration of a number of bedrooms. A new floor covering was due to be fitted in the dining room. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 6 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. Woodcrofts DS0000005202.V339428.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 Woodcrofts DS0000005202.V339428.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 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information and opportunities to visit before choosing to move in are available and people are assessed prior to admission to ensure that their needs can be met. EVIDENCE: As part of the inspection process the care files of three people who had moved into the home recently were looked at. A multidisciplinary approach to the personal care and support of residents is in operation and individuals are encouraged to maintain contact with their respective health and social care professionals. A mixture of pre-admission documentation was seen on the three files looked at during the visit. These ranged from documentation completed by the home either before or shortly after admission to forms completed by the placing authority and subsequently used by the home. A gradual process of introductory visits and activities is usually undertaken prior to admission to the home and documentary evidence seen during the visit confirmed that this had taken place. Overall the assessments looked at contained enough information for staff members to be able to meet an individuals needs. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents care plans seen provided sufficient information for staff members to be able to take appropriate action to meet an individuals needs. EVIDENCE: Residents have both a main and key-worker file. The latter contains ongoing notes and a record of personal hygiene. The main file contains the care plan, review notes, correspondence etc. Those seen as part of the case tracking process covered identified care needs and generally identified and confirmed how the respective individual’s needs would be met. There was written evidence to confirm that care plans were being reviewed as and when necessary. The care plans seen also contained evidence of consultation with residents or their family members where applicable. As with the assessment documentation care plans and review documentation was a mixture of either the home’s or the placing authority. Records relating to support from other professionals such as GP visits, Community mental Health Team [CMHT] contact etc were also available. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 10 Whilst inspecting a variety of care plans we noted that the files for people who had lived in the home for a considerable time contained lots of dated information; we consider that they would benefit from being pruned. The residents spoken with during the inspection all said that the standards of care provided were very good and that they had been able to express their opinions and wishes about their daily routines. It was also seen throughout the visit that residents were being treated with courtesy, respect and good humour by staff. Staff members were seen to be interacting with individuals in an appropriate and respectful manner. The risk assessments seen in the residents’ files had been completed appropriately. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were positive about the home and the support they received in order to maintain contact with friends and family and to make choices about their daily lives. EVIDENCE: Whilst none of the current residents are engaged in either paid or voluntary employment or attend any training courses there are opportunities to do so if requested. A number of people attend day services. One person spoken to said that they did not wish to attend day services but would like more activities to be provided; the person did not give any further details regarding this. Residents living in the home are able to develop and maintain skills, which will aid their personal development; these include opportunities to choose and buy items for themselves or their rooms. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 12 The people living at Woodcrofts confirmed that they were free to come and go as they wished and that they had their own personal network of friends and relatives either within or external to the home. The home is similar to the other domestic properties in the neighbourhood this allows people to become part of the local community. Residents confirmed that routines within the home were flexible and that they were able to make choices in many areas of daily living, for example times of rising and retiring, where to spend time and with whom. One of the residents said that he had lived in a number of other places but Woodcrofts was the best and he felt happy and settled, another said that, “I would not know what to do without staff”. Staff members were observed to knock on the door and to await permission before entering a resident’s bedroom. Mail is given to residents unopened. Meals are usually eaten in the dining room. All of the residents that commented said that they enjoyed the meals provided for them and their tastes and choices were taken into account. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were positive about the home and the support they received so they could maintain as much independence as possible. EVIDENCE: Residents are able to live their lives as independently as possible. It was seen during the visit that the staff members treated individuals with respect and dignity. Personal care, if required is provided in private and takes into account an individual’s preferences and needs. Staff members do this by respecting privacy and offering choices. Staff members spoken to have a good understanding of the people they were supporting and were able to meet their diverse needs. Staff members spoken with had a good understanding of the people they were supporting and were able to meet their diverse needs; they continually monitor a residents’ health needs and there was evidence to show that they were receiving appropriate support from health care professionals. This included GPs, Community Psychiatric Nurses [CPN], optician, dentist and chiropodist. The changing needs of individuals are discussed as and when required and we Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 14 were able to see this in practice during the visit when the deputy was seen to be arranging an appointment for one of the residents. Another person was seen to be going out with their CPN as part of an ongoing support package. Medicines are administered using a blister pack system provided by a local pharmacist. No major issues concerning the medication system were seen during the inspection visit. The two staff members who administered medication during the visit both confirmed that they had received training in this area. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to complain and action is taken to respond to their concerns. Adult protection training for staff is available to ensure the continued safety of residents. EVIDENCE: There is a written complaints procedure for the home. Those residents that commented said that they would inform the home or deputy manager or senior staff members if they had any concerns or complaints. They also said that they felt confident that appropriate action would be taken. People confirmed that any minor issues are dealt with as they arise. The two survey forms returned also confirmed that they knew how to make a complaint. The home has an Adult Protection procedure (including Whistle Blowing), which complies with the Public Disclosure Act 1998 and the Department of Health Guidance “No Secrets”. The deputy manager is a member of Halton Borough Councils’ adult protection committee. Some of the staff members have received training in adult protection procedures; the deputy manager explained that this has been done in conjunction with Halton Borough Council. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained, with suitable facilities so that residents live in a safe, clean and comfortable home. EVIDENCE: A tour of the building was undertaken; this included communal areas and a number of bedrooms. Furnishings, fittings and lighting of the communal rooms are domestic in character. Bedrooms seen during the inspection were personalised and contained items of furniture belonging to residents’. There is a lounge available for the residents who smoke; as this is well used the decoration, carpeting and furniture is looking tired and worn and would therefore benefit from refurbishment. The other communal lounge areas within the home were of a good standard and were comfortable and homely. The dining room that is also used by people aside from mealtimes was having a new floor covering fitted. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 17 The premises are similar to the other domestic houses in the neighbourhood this allows people to become part of the local community. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff recruitment procedures are not robust enough to ensure that residents are safe from risk. EVIDENCE: Staff on duty and rotas seen demonstrated that staffing levels and the skill mix of staff was adequate to meet the diverse needs of the residents within the home. Two staff members are on duty between the hours of 8.00am and 10.00pm. At night there is one waking night staff. A member of the management team lives on the premises. Staff members were seen to be cheerful and friendly and all of the residents spoken with during the visit were complimentary about their attitude and competence. The AQAA states that the staff members working in the home have either achieved an NVQ qualification or are working towards it. The staff members spoken with confirmed this. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 19 The home’s recruitment procedures should be robust in order to protect vulnerable residents in their care. The files for the two most recently appointed staff members were examined. Neither of them contained all of the information detailed in both the Care Homes Regulations 2001 and the accompanying standard. Whilst POVA first checks had been received prior to the commencement of employment there were issues with the references for both people. In one instance the reference from the last employer was received two weeks after employment had commenced. Although this was the only reference on file a satisfactory explanation as to the reasons why there was no other reference was provided. There were no references on the file of the other staff member. Although the reason for this was also explained verbally by the deputy manager it was difficult to assess the overall quality of the recruitment policy due to the issues noted and the lack of any documentary evidence. Although the reason was different on this occasion this is an outstanding requirement from the previous two inspections visits. During a discussion with the deputy manager he explained that it was his intention to appoint an administrator; he did not feel that there was enough time for him or the staff members to undertake all of the administrative tasks within the home and this was one of the reasons why there had been problems with recruitment and other administrative tasks such as pruning care files. We also consider that this appointment would improve the home’s systems and may improve the quality of the service provided to residents. The staff training records for the newly appointed staff members showed that they had been provided with a code of practise booklet, and had received information on the following matters; fire procedure, including a video, the home’s statement of purpose, whistleblowing, disciplinary procedure, sickness/absence, adult protection guidelines, confidentiality, philosophy document, risk management policy, sexuality and relationships and gifts; however this record had been signed by the senior staff member responsible for inducting new staff and not by the new employee. Similarly the senior had only signed policies on health and safety and COSHH. Although one of the new staff members confirmed that she had worked as a supernumerary when she had started work and had spent time reading the policies and procedures it is considered to be good practice to ensure that both the senior and the new staff member sign the record. During a discussion with this senior she confirmed that in the future she would ensure that the new employee would also sign this record. It is also understood from a conversation with the deputy manager that it was his intention to use the Skills for Care Induction Standards in the near future. The staff members spoken with confirmed that they had received training in areas such as moving and handling; person centred planning, medication awareness, first aid and fire safety. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 20 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 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well run and managed on a day-to-day basis and there are appropriate procedures in place to make sure that people are safe. EVIDENCE: Woodcrofts has an experienced and competent owner/manager who is registered with the Commission for Social Care Inspection, whilst he is no longer in day-to-day control of the home he is there on a daily basis. The deputy manager is now carrying out this role and he is currently undertaking the Registered Managers Award. During a discussion it was explained that the deputy manager intends to apply to The CSCI to become the home manager as soon as he has completed his award. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 21 A quality assurance system using survey forms was in the process of being undertaken, a sample has been provided. Although a suggestion box was available for residents to use it is understood that any issues are raised and dealt with as part of the day-to-day operation of the home. Residents confirmed that they knew how to raise issues and that they were more than happy with the service being provided to them. The maintenance records seen demonstrated that a number of service contracts were in place. The manager explained that they were waiting for a new gas safety certificate, as the contractor who normally did this was no longer able to do it. The fire precautions record book demonstrated that checks of the alarm system, emergency lighting, fire drills and staff training in fire safety were taking place. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 22 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 X 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 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 23 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 YA34 Regulation 19 Requirement A thorough recruitment procedure that fully protects the people receiving a service must be implemented. [Timescale of 07/09/06 not met]. Timescale for action 12/10/07 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. 2. Refer to Standard YA6 YA34 Good Practice Recommendations The residents care files should be sorted and any out of date information should be archived in a separate file. An administrator should be appointed, this would improve the home’s systems and may improve the quality of the service provided to residents. Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Woodcrofts DS0000005202.V339428.R01.S.doc Version 5.2 Page 25 - 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!