Inspection on 23/03/06 for Woodcrofts

This inspection was carried out on 23rd March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 6 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 12/10/07

Woodcrofts 30/09/05

Woodcrofts 06/12/04

Woodcrofts 30/07/04

Woodcrofts 20/02/04

Woodcrofts 20/10/03

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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 23rd March 2006 09:55 Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 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.V284781.R01.S.doc Version 5.1 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.V284781.R01.S.doc Version 5.1 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.V284781.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of Service Users must not exceed 21 21 of the Service Users may be MD 7 of the Service Users may be MD (E) Date of last inspection 30th September 2005 Brief Description of the Service: Woodcrofts is a privately owned two-storey care home providing accommodation to 21 adults with mental health needs [of whom 7 may be aged over 65]. Four members of the family, two of which live 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. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Paul Ramsden carried out this unannounced inspection on 23 March 2006. The deputy manager was on duty together with the agreed numbers of care staff. The home manager arrived shortly after the inspection started. Seventeen people were living in the home at the time of the visit. During the inspection ten residents, the manager, assistant manager and one of the staff on duty were spoken with. A range of care, health and home records were examined and a tour of the premises, including all lounges, other shared areas and a number of bedrooms, was undertaken. What the service does well: What has improved since the last inspection? What they could do better: A requirement regarding care plans has been made. Improvements to both the recruitment and induction procedures are needed. More staff members could undertake NVQ training. A system for reviewing the quality of care needs to be implemented. Two requirements relating to the emergency lights [This is an outstanding requirement from the previous inspection visit] and staff training in fire safety have been made. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 6 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. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 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.V284781.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents are assessed prior to admission to ensure that the home will be able to meet their needs. New residents are usually introduced into the home on a planned and gradual basis. EVIDENCE: As part of the inspection process the care files of people living at the home were reviewed. Pre-admission assessments that demonstrated that the resident’s individual needs were being assessed in an accurate and consistent way had been carried out. Those seen contained enough information for staff to be able to meet individual needs. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 Although residents have a care plan that shows how their individual needs are being met the file for one resident was unavailable for inspection. 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. Whilst looking at these files as part of the inspection process it was seen that whilst the key-worker file for a resident admitted in September 2005 was in the filing cabinet the main file was not available. The manager was unable to explain the reason for this omission. See requirement No 1. The other main files looked at provided staff members with the necessary information for them to look after a person’s needs; they 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 families/advocates. Records relating to support from other professionals such as GP visits, social worker contact etc were available. Residents confirmed that they were able to make decisions; they also said that they are able to voice their opinions to the manager, assistant manager or Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 10 staff members on a formal and informal basis. Residents are able to participate in a variety of activities as part of an independent lifestyle. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 16 and 17 Routines at the home are flexible to suit residents’ individual preferences. EVIDENCE: Residents living at Woodcrofts are free to come and go as they please and have their own personal networks of friends and relatives either within or external to the home. It is similar to the other domestic properties in the neighbourhood, enabling individuals to integrate into the local community. 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. 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. Staff members were observed to knock on the door and to await permission before entering a resident’s bedroom Meals are usually eaten in the dining room. All of the residents that commented said that the food was good and that choices were available. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The health needs of each resident are being appropriately met. 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. There was evidence during the visit to demonstrate that the residents’ health and general wellbeing was being monitored and where necessary appropriate action taken. The home uses a blister pack system dispensed by a local pharmacist. An inspection of medication and the Medication Administration Record [MAR] sheets indicated that medication within the home was being appropriately managed. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Neither of the standards was inspected during this visit. The key standards were assessed as having been met during the previous inspection. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 and 30 The home provides good facilities to meet the needs of the residents accommodated. Standards of hygiene and cleanliness are satisfactory. EVIDENCE: The premises are similar to the other domestic properties in the neighbourhood allowing residents to integrate into the local community. A tour of the premises was undertaken; this included all communal areas and a number of bedrooms. The bedrooms seen were personalised with items of furniture and photographs. All bedroom doors have locks, which can be overridden in an emergency. Residents are able to have a key if they wish. The furnishings and fittings are domestic in character. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Improvements to both the recruitment and induction procedures are needed. EVIDENCE: The home does not yet have 50 of its staff members qualified to NVQ level 2. See recommendation No 1. The staff members seen on the day were cheerful and friendly and were seen to have a good relationship with the people that they were caring for. Two staff members are on duty between the hours of 8.00am and 10.00pm. At night there is one waking night staff. Two members of the management team live on the premises. The home’s recruitment procedures should be robust in order to protect vulnerable residents in their care. The file for the most recently appointed staff member was examined. This did not contain all of the information detailed in both the Care Homes Regulations 2001 and the accompanying standard. There were no references or CRB disclosure on the file. There was no induction record available for this same person. See requirement No 2. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The registered manager is no longer in day-to-day control of the home. There is no formal quality assurance system in place. The emergency lights are still not being tested monthly. EVIDENCE: Although Woodcrofts has an experienced and competent owner/manager who is registered with the Commission for Social Care Inspection he is no longer in day-to-day control of the home. The assistant manager is now undertaking this role. The relevant documentation to address this issue has been sent to the home. The assistant manager is in the process of completing an NVQ level 4 in management. See recommendation No 2. There is no consistently obtained and verifiable quality assurance system based upon seeking the views of residents in place. See requirement No 3. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 17 The fire precautions record book was inspected, whilst this demonstrated that the alarm system was being checked at appropriate intervals and fire drills were being carried out the emergency lights were still not being tested monthly as required during the previous inspection. It was also noted that the names of staff receiving training in fire safety was not being recorded. See requirement No’s 4 and 5. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 18 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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 1 X Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 17 Requirement The registered person must ensure that all care plans are available for inspection. The registered person must ensure that a thorough recruitment and induction policy is implemented. The registered person must establish and maintain a system for reviewing the quality of care provided at the home. The registered person must ensure that the emergency lights are tested on a monthly basis. [Timescale of 30/11/05 not met] The registered person must ensure that the name of all staff members receiving training in fire prevention is recorded. Timescale for action 23/03/06 2 YA35YA34 18, 19 23/03/06 3 YA39 24 31/07/06 4 YA42 23 [4] 23/03/06 5 YA42 23 [4] 23/03/06 Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 20 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 YA32 YA37 Good Practice Recommendations The registered person should ensure that at least 50 of its’ staff members are trained to NVQ level 2. The registered persons should ensure that the registered manager attains level 4 NVQ in management and care. Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodcrofts DS0000005202.V284781.R01.S.doc Version 5.1 Page 22 - 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. 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