Inspection on 30/09/05 for Woodcrofts

This inspection was carried out on 30th September 2005.

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 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 12/10/07

Woodcrofts 23/03/06

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 30th September 2005 2:15 Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 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.V252089.R01.S.doc Version 5.0 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.V252089.R01.S.doc Version 5.0 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.V252089.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 21 of the Service Users may be MD 7 of the Service Users may be MD(E) The total number os Service Users must not exceed 21 Date of last inspection 6th December 2004 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.V252089.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 30 September 2005 by Paul Ramsden and lasted four hours and twenty-five minutes. The deputy manager was on duty together with the agreed numbers of care staff. The home manager arrived shortly after the inspection started. Eighteen people were living in the home at the time of the visit. During the inspection twelve residents, the manager, deputy 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: Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 Page 6 The deputy manager said that he would like residents to make more use of community facilities and feels that some of them would benefit from having an advocate. Emergency lights must be tested monthly. A requirement regarding this has been made. 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.V252089.R01.S.doc Version 5.0 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.V252089.R01.S.doc Version 5.0 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 and 4 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 the two most recent admissions to 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. It was noted that the daily living and needs assessment for one of the residents had not been signed and dated. This was passed on to the deputy manager who stated that he would address the issue. The deputy manager explained that a multidisciplinary approach to the personal care and support of residents is in operation and people are encouraged to maintain contact with their respective health and social care professionals. A gradual process of introductory visits and activities are usually undertaken prior to admission to the home. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 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, 7 and 9 All residents have a care plan that shows how their individual needs are being met. EVIDENCE: The four care plans seen as part of the inspection process provided staff members with the necessary information for them to look after a person’s needs. Those inspected covered all 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 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. A new care planning system is in the process of being implemented. Residents confirmed that they were able to make decisions; they also said that they are able to voice their opinions to the manager and staff on a formal and informal basis. There are regular meetings held at the home. Residents are able to participate in a variety of activities as part of an independent lifestyle. This is carried out through a process of risk assessment. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 Page 10 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): 12, 13, 15, 16 and17 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. Whilst none of the current residents are engaged in either paid or voluntary employment there are opportunities to do so if requested. A number of individuals attend a day centre. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 Page 11 Meals are usually eaten in the dining room. There is a menu that has the flexibility to meet individual needs and choices. All of the residents that commented said that the food was good and that choices were available. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 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 and 19 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 individual service user preferences and needs. The residents’ health and general wellbeing is monitored and where required they are assisted to maintain contact with their respective health and social care professionals. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 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): 22 and 23 Residents are able to voice their opinions and are confident that appropriate action would be taken to address any problems or complaints. Appropriate complaint and adult protection policies and procedures are in place. EVIDENCE: The home’s complaints procedure explains to residents and their representatives how to make a complaint. Residents spoken to on the day of the inspection confirmed that they knew who to speak to if they had a concern or 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”. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 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 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 and the home has an ongoing maintenance plan for the decoration of the premises. Since the previous inspection visit the main lounge has been redecorated and some new furniture has been provided. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 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): 33 Staff members were seen to be working positively with residents to improve the quality of life of people living in the home. EVIDENCE: Staff on duty and rotas seen demonstrated that staffing levels and the skill mix of staff were adequate to meet the needs of the residents within the home. 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 and are available during the night if needed. The management teams hours are in addition to the above levels. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 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 and 42 The home is being well run and managed on a day-to-day basis. The emergency lights are not being tested at appropriate intervals. EVIDENCE: The home has an experienced and competent owner/manager who is registered with the Commission for Social Care Inspection. There is a four strong management team at Woodcrofts to support him. The owner/manager does not have a qualification at level 4 NVQ in management and does not undertake periodic training, but is well appraised of changing needs within the service and is involved with the Care Home Owners’ Association. The assistant manager, who is the son of the registered persons, is in the process of completing an NVQ level 4 in management and care at the time of the visit, however this qualification is an expectation of the registered manager. See recommendation No 1. The fire precautions record book was inspected, whilst this demonstrated that the alarm system and fire drills/training were being carried out at appropriate Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 Page 17 intervals the emergency lights were still being tested twice yearly rather than monthly which is the accepted frequency. See requirement No 1. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodcrofts Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000005202.V252089.R01.S.doc Version 5.0 Page 19 NO 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 YA42 Regulation 23 [4] Requirement The emergency lights must be tested on a monthly basis. Timescale for action 30/11/05 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 YA37 Good Practice Recommendations The registered persons should ensure that the registered manager attains level 4 NVQ in management and care by 2005. Woodcrofts DS0000005202.V252089.R01.S.doc Version 5.0 Page 20 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.V252089.R01.S.doc Version 5.0 Page 21 - 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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