Inspection on 15/05/06 for Woodham Grange

This inspection was carried out on 15th May 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodham Grange 07/01/08

Woodham Grange 02/05/07

Woodham Grange 07/12/05

Woodham Grange 02/02/05

Woodham Grange 03/09/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Woodham Grange Burn Lane Newton Aycliffe Durham DL5 4PJ Lead Inspector Paul Emmerson Unannounced Inspection 15 May 2006 11:30 Woodham Grange DS0000007523.V294139.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 Woodham Grange DS0000007523.V294139.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. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodham Grange Address Burn Lane Newton Aycliffe Durham DL5 4PJ 01325 310493 01325 310493 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) londonroad@tiscali.co.uk Milbury Care Services Limited Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Woodham Grange is a large two-storey property, situated in its own grounds. It was purpose built to accommodate people who use wheelchairs. The home is owned by Milbury Care Services Limited and is registered to provide care for up to 8 adults who have learning disabilities, complex needs and/or physical disability. The home is in the Woodham area of Newton Aycliffe, within walking distance of the town centre and local amenities. From information provided by the home, the current scale of charges ranges from £863 to £937 per week. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours, on the morning and afternoon of Monday 15 May 2006. In line with current CSCI policy on ‘Proportionality’, the inspection focused upon a number of key standard outcomes for service users. The inspector looked around the building and a number of records were examined. The manager, deputy manager and 5 members of staff were interviewed. Within the limits of their communication and understanding, service users were also spoken to. On the day of the inspection there were no visitors to the home. However, 5 relatives / visitors completed and returned CSCI’s ‘Comment Cards’ about the service. All expressed general satisfaction with the home. One person wrote, “Highly Satisfied”. What the service does well: What has improved since the last inspection? What they could do better: 6 requirements have been made as a result of this inspection. These are listed on pages 26 & 27 of this report. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 6 To ensure that service users’ needs can be met, staffing levels must be maintained. Care planning and a number of administrative documents need to be updated. Although it is acknowledged that some redecoration work has been carried out, as highlighted in previous inspection reports, the following repair / maintenance work is still required: • The kitchen floor requires renewal. • There are a number of rooms, which still need decorating. • Carpets in 2 bedrooms, the hallways, conservatory and corridors look tired and worn and need to be replaced. • The laundry requires redecoration and a review of working space to ensure easier accessibility by service users and staff. An action plan setting out work to be undertaken and timescales for completion must be forwarded to CSCI. The Care Homes Regulations 2001 require that (amongst many other things) the service provider is responsible for ensuring that the home is kept reasonably decorated. The service provider must pay any costs associated with this responsibility. However, documents in the home show that the service users who occupy 2 of the 4 recently redecorated bedrooms have paid for the work to be done - £250 & £280. This money must be refunded. 9 recommendations have also been made as a result of this inspection and are listed on page 27 & 28 of this report. A number of these are about administrative processes, but some are to suggest ways of improving the care and services people receive at Woodham Grange. 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. Woodham Grange DS0000007523.V294139.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 Woodham Grange DS0000007523.V294139.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Overall the outcomes for service users under these Standards are good. Admissions to the home are appropriately managed. Service users’ needs are assessed prior to any admissions. EVIDENCE: Woodham Grange is registered to accommodate up to 8 people with learning disabilities. On the day of the inspection there were 7 people living there (there is 1 vacancy). One of the 7 residents was away on holiday. The most recent admission to the home was in July 2001. Although the inspector was unable to communicate with service users about their experience of moving in to Woodham Grange, there is documentary evidence to show that prior to admission appropriate assessments were conducted. After admission, more detailed care plans were prepared. The home has its own assessment and care planning documents for this purpose. Copies of assessment documentation and other relevant information from the Local Authority Social Services Department were also obtained. Service users considering a move to Woodham Grange would be welcome to visit with relatives, have a meal and stay overnight if necessary. In this way service users could get to know the home before moving in. Any move into Woodham Grange would be on a six-week trial basis. At the six-week stage a formal review meeting would be held to consider permanency. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 9 Woodham Grange has a Statement of Purpose and a Service Users’ Guide to provide service users, and any potential service users, with information about the home. These documents are available in a pictorial format. However, it should be noted that wherever possible the views of service users should be included. Woodham Grange DS0000007523.V294139.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Overall the outcomes for service users under these Standards are good. Staffing levels permitting, service users’ needs are met. Within the limits of their communication and understanding service users are offered choice and any decision-making is appropriately supported. Care plans reflect service users’ diverse needs and aspirations. EVIDENCE: The service users accommodated are on the whole dependent upon staff, family and significant others to make choices and decisions on their behalf and best interests. Most decisions are limited by the individuals’ learning disability and understanding, however such limitations are noted on personal files. Nevertheless, within the limits of their communication and understanding choice is offered to service users and preferences are provided for. Although unable to speak to express herself, one service user was seen to use physical contact to attract the attention of staff. Staff responded appropriately and asked her a number of questions to ascertain what she wanted from them. Staff were seen to ask service users if they wanted a drink. In this albeit small way, staff were seen to be respecting service users’ rights and choices. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 11 Although in the process of being reviewed to adopt a pictorial and user-friendly style, care plans have been prepared for all service users and these documents contain much information. Likes, dislikes and lifestyle preferences are recorded. Although some reviews need to be arranged, care reviews have been held or scheduled for most of the service users. Risk assessments have also been prepared and risk management arrangements ensure that service users can live as independent a lifestyle as possible. The home operates a key-worker system, and from discussions with staff and observations made by the inspector, staff are familiar with the needs of the people accommodated. Day-to-day communication in the home and recorded handovers between staff ensures that any changes in need are identified and brought to the attention of other staff. It is noted that since the last inspection, to enhance communication and provide an additional forum to consider care planning arrangements and any other issues in the home, house meetings have been reconvened and are now being held more regularly. Although the inspector was unable to communicate with service users to any significant degree, the inspector spent time in their company and spoke to the manager, deputy manager and staff on duty in the home. During the inspection there were no visitors to Woodham Grange. However, 5 relatives / visitors completed and returned CSCI’s ‘comment cards’ about the service. All expressed general satisfaction with the home. One person wrote, “Highly Satisfied”. However, another person wrote that they felt they were not always kept informed of important matters affecting their relative. The service users accommodated have a high level of diverse care needs and can exhibit some quite challenging behaviour. However, service users were seen to be well cared for and comfortable in their living environment. Many of the staff have worked at Woodham Grange for a number of years and know the service users well. Care planning arrangements in the home are being revised. Documents to be used are easier to read and pictures are being used to help understand them. Although some reviews are required, existing care plans and other documents contain much information and are informing the delivery of service users’ care. For example, one of the care plans examined considers challenging behaviour in depth: any events or circumstances that may trigger such behaviour and the various responses that staff can use to de-escalate it are documented. Woodham Grange DS0000007523.V294139.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Overall the outcomes for service users under these Standards are adequate. Staffing levels permitting, activities are arranged and service users live as part of the local community. Contact with family / friends is supported. Dietary needs are met. EVIDENCE: Staff spoken to confirmed that activities are arranged wherever possible. For example one service user attends a day-care placement at ‘The Oaks’ and attends a project called ‘Wishing Well’. Transport permitting, other service users use a nearby hydro-pool and attend Darlington’s Gateway Club. The home has a large wheel chair adapted mini-bus, which can be used as transport. Activity plans are kept for all service users and these record activities planned and arranged. However, due to the shortage of staff able to drive the home’s mini-bus, most activities outside the home are reliant on service users and staff walking; for example to the town centre. Trips out and activities further away are thus more difficult to arrange. As highlighted in previous inspection Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 13 reports, if additional drivers cannot be found, alternative forms of transport should also be considered. Further, as also highlighted in previous inspection reports, although the minibus is underused, service users are still paying contributions towards it from their Disability Living (Mobility) Allowances. For most people this amounts to some £15 per week. If the mini-bus service is not being provided, as highlighted in the previous inspection report, this money should be refunded. Contact with family and friends is supported. On the day of the inspection, one service user was on holiday arranged through a day service she attends. It is noted that holidays are also being planned for other residents. A wholesome and nutritious diet is provided. Fresh meat, fruit and vegetables were seen to be available. Where service users require assistance with dining it is provided. Wherever possible, service users are given a choice of meals and preferences are catered for. However, the menu currently being used refers to another care home. Menus should be reviewed, and where necessary discussed with dieticians, to ensure that the needs and preferences of service users living at Woodham Grange are accommodated. Woodham Grange DS0000007523.V294139.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Overall the outcomes for service users under these Standards are good. Personal and healthcare needs are appropriately met. Any medicines required are dealt with correctly. EVIDENCE: Although the inspector was unable to communicate with service users to any significant degree, the inspector spent time in their company. The service users accommodated have a high level of diverse care needs. However, they were seen to be well cared for and comfortable in their home. The people who live at Woodham Grange are on the whole dependent upon staff and others to make choices and decisions on their behalf and best interests. However, within the limits of their communication and understanding, service users’ preferences are accommodated. From observations made by the inspector and from discussions with management and staff, where personal support is required it is provided appropriately. Care plans examined show that wherever possible, service users are provided with guidance and encouragement to undertake their own selfcare tasks, thus promoting independence in a dignified and respectful manner. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 15 Although care plans need to be reviewed and updated, and some care plans refer to physiotherapy interventions required from staff that are not being carried out, the care plans read by the inspector were seen to document service users’ diverse personal and health care needs and the actions required and being taken to meet them. Care plans are thus a record of the care provided, but also inform the delivery of care within the home. They are also being revised into a pictorial user-friendlier format. Nevertheless, as highlighted in the previous inspection report, care plans must be reviewed and updated. Contact should be made with the community physiotherapist to ensure appropriate interventions required by staff are carried out. Where necessary, contact must be made with Care Managers to arrange care reviews. Although none of the service users accommodated retain, control or administer their own medication, because of their needs and dependency this is considered appropriate. Senior support workers administer medication in the home. From discussions with staff, these people have received appropriate training in this area. Other staff also receive instruction to understand the medicines prescribed, potential side effects etc. Medicines were seen to be stored appropriately. The home uses a monitored dosage system. There are adequate policies, procedures and systems in place relating to the receipt, recording, storage, handling, administration and disposal of medicines. Where medicines need to be stored in a refrigerator, at or below a certain minimum temperature, a separate small fridge has been obtained to store them. However, stock of one medicine - to be taken as and when needed - was found to be past its ‘use by date’. It is recommended that any audit of medicines held in the home should include a check of ‘use by dates’. Where necessary up to date supplies of medicines should be obtained. Woodham Grange DS0000007523.V294139.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Overall the outcomes for service users under these Standards are adequate. Within the limits of their communication and understanding, service users’ views are obtained. Complaints and adult protection systems in the home serve to safeguard service users. EVIDENCE: The home, through its parent organisation, has detailed complaints and adult protection procedures. Copies of these were seen to be available for staff use. Pictorial information about complaints, how and who to make them to, is included in the home’s ‘Service Users Guide’. Since the last inspection the home has received one complaint, which was dealt with appropriately. House meetings, serve as an additional forum to discuss any issues. Staff interviewed voiced commitment to the service users they work with and their rights. However, only some staff have received training specifically relating to adult protection. Although it is acknowledged that issues relating to abuse and adult protection are considered in NVQ and other such courses, as highlighted in previous inspection reports, staff should receive training in adult protection. Policy and procedure documents relating to adult protection provide information and guidance to staff. A copy of ‘Durham & Darlington Adult Protection Committee’s Inter-Agency Adult Protection Policy & Procedures’ on abuse and the protection of vulnerable adults is now available in the home. However, as highlighted in the previous inspection report, the home’s adult protection policies and procedures should be reviewed and where necessary amended, to reflect any local protocols, contact information and the initial Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 17 action to be taken (things to do and things not to do) if an allegation of abuse arises. Woodham Grange DS0000007523.V294139.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30. Overall the outcomes for service users under these Standards are adequate. Woodham Grange is generally clean, tidy and safe. Service users’ rooms are personalised. However, outstanding repairs and redecoration work detracts from the once homely environment. EVIDENCE: Woodham Grange provides residential care for up to 8 adults (aged 18 – 65) with learning disabilities in 8 single bedrooms. The home is situated in a residential area in the Woodham district of Newton Aycliffe, yet relatively close to the town centre. The home is a large, detached property, which stands in large gardens. Five of the home’s bedrooms are located on the ground floor of the home, with three additional bedrooms on the first floor. There is a bathroom on the ground floor and a bathroom on the first floor. The first floor bathroom has a walk in shower. The home’s ground floor bathroom has recently been refitted with a hi-low bath, an over bath changing table and a ceiling / track hoist. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 19 However, as highlighted in previous inspection reports, similar adaptations should be carried out to the first floor bathroom, which should be refitted to better meet the needs of people with physical impairments. The financial implications associated with this need to be considered within any business plans and budgetary arrangements for the continued running of the home. The inspector looked around the building, which was found to be clean, tidy and odour-free. Service users’ bedrooms have been personalised and new furniture has recently been acquired for the lounge. However, long outstanding repairs and redecoration work detracts from the once homely environment. As highlighted in previous inspection reports: • • • • The kitchen floor requires renewal. A number of rooms need decorating. A number of carpets need replacing. The laundry requires redecoration and a review of working space to ensure easier accessibility by service users and staff. In addition to these works, ‘Maintenance Request Forms’ submitted by the home to Milbury Care Service Limited’s Estates Department after recent Health & Safety audits must also be addressed. For example, the crack in the patio retaining wall. An action plan setting out work to be undertaken and timescales for completion must be forwarded to CSCI. It is of concern that service users’ money has been used to decorate their bedrooms. Such work is the responsibility of the service provider. As highlighted in the previous inspection report, money paid by 2 service users to decorate their bedrooms (£250 & £280) must be refunded. Woodham Grange DS0000007523.V294139.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. Overall the outcomes for service users under these Standards are adequate. Sufficient staff are employed. The home has a settled and well-trained staff team. EVIDENCE: Care is provided by a committed, well-trained staff team. Although in recent times the home has been operating with uncertain staffing and management arrangements, new management appointments have been made and staffing levels are generally more settled. A number of staff have worked at Woodham Grange for a number of years and know the service users well. Virtually all staff have NVQ (National Vocational Qualification) qualifications at level 2 or 3. Most of the home’s staff have also completed LDAF (Learning Disability Award Framework) training courses. Although some updates are required and some courses have been difficult to access, training in for example First Aid, Moving & Handling, Food Hygiene etc. is provided by Milbury Care Services Limited through its regional training plan. It is acknowledged that an audit of staff training needs has been carried out. However, as highlighted in the previous inspection report, staff training updates must be provided where required. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 21 From discussions with staff, safe recruitment practices are followed. Recruitment procedures through Milbury’s regional office are considered to be satisfactory and safe. Appropriate references are obtained and CRB (Criminal Records Bureau) disclosure checks are carried out. Although from discussions with the new manager, staff records are in need of some audit, these documents are available in the home. However, staff records should be reviewed to ensure that appropriate records are available and held in the home. Due to the needs of the service users accommodated, the agreed staffing levels for the home require at least four staff to be on duty throughout the waking day. With night staffing arrangements (1 person awake, 1 person asleep) this equates to 492 weekly care hours for the home. From discussions with staff, rosters and other documents examined, because of some staff vacancies and some sickness, four staff are not always rostered. As highlighted in previous inspection reports, staffing hours within the home must be appropriate to the needs of the service users being accommodated. It is also recommended that the review of service users’ needs and associated staffing levels being carried out in the home should be completed as soon as possible. Where necessary any adjustments to staffing arrangements should be made. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 22 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 & 42. Overall the outcomes for service users under these Standards are adequate. Woodham Grange runs well. However, although quality assurance systems are in place, remedial action to rectify issues raised takes too long. EVIDENCE: A new manager has been appointed and has applied to become registered with CSCI. Although relatively new to the post, this appointment (together with a new deputy manager appointment, Milbury’s operations manager and senior support workers within Woodham Grange) have brought greater stability to the running of the service. To enhance communication in the home, house meetings have been reconvened. Appropriate systems are in place to ensure service users’ health and safety is protected. For example, risk assessments and control measures relating to the safe use of bed-rails. Monthly reports required under Regulation 26 of the Care Homes Regulations 2001 are provided to CSCI detailing the action required to address shortfalls in Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 23 the home. Milbury Care Services Limited also has its own policies, procedures and systems relating to quality assurance. Regular audit checks are undertaken and forwarded to the regional office. However, failure to address outstanding issues renders the company’s quality assurance systems meaningless. As highlighted in the previous inspection report, quality assurance systems should be reviewed to ensure any issues arising are addressed in a timelier manner. As highlighted in previous inspection reports, until recently Milbury Care Services Limited had a local administrative base, however this has moved to Sheffield. To provide sufficient administrative support to the home, comply with data protection legislation and reduce difficulties and delays experienced with forwarding paper work, it is recommended that the home should acquire IT equipment and utilise electronically communicated alternatives. Further, to ensure that the home is competently managed and accountable, annual development, business and financial plans for the establishment should be prepared and be available for inspection on the premises. Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 24 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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 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 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 25 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 YA18 Regulation 15(2)(b) Requirement As highlighted in the previous inspection report, care plans must be reviewed and updated. Where necessary, contact must be made with Care Managers to arrange care reviews. The previous timescale for action of 1/3/06 was not met. As highlighted in the previous inspection report, care plans must be reviewed and updated. The previous timescale for action of 1/3/06 was not met. As highlighted in previous inspection reports: • The kitchen floor requires renewal. • A number of rooms need decorating. • A number of carpets need replacing. • The laundry requires redecoration and a review of working space to ensure easier accessibility by service users and staff. The previous timescale for action of 1/3/06 was not met. As highlighted in the previous inspection report, money paid by 2 service users to decorate DS0000007523.V294139.R01.S.doc Timescale for action 01/07/06 2. YA19 15(2)(b) 01/07/06 3. YA24 23 01/07/06 4. YA24 23(2)(d) 01/07/06 Woodham Grange Version 5.2 Page 26 5. YA32 18(1) 6. YA33 12(1&2), 17(1,2&3) their bedrooms (£250 & £280) must be refunded. The previous timescale for action of 1/3/06 was not met. As highlighted in the previous inspection report, staff training updates must be provided where required. The previous timescale for action of 1/3/06 was not met. As highlighted in previous inspection reports, staffing hours within the home must be appropriate to the needs of the service users accommodated. The review of service users needs and required staffing levels being carried out in the home should be completed as soon as possible and where necessary any adjustments to staffing arrangements should be made. The previous timescale for action of 1/2/06 was not met. 01/07/06 01/07/06 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 YA12 Good Practice Recommendations As highlighted in previous inspection reports, if additional drivers cannot be found, alternative forms of transport should also be considered. Although the mini-bus is underused, service users are still paying contributions towards it from their Disability Living (Mobility) Allowances. For most people this amounts to some £15 per week. If this service is not being provided, this money should be refunded. Menus should be reviewed, and where necessary discussed with dieticians. Contact should be made with the community physiotherapist to ensure appropriate interventions DS0000007523.V294139.R01.S.doc Version 5.2 Page 27 2. 3. YA17 YA19 Woodham Grange 4. 5. YA20 YA23 required by staff are carried out. Any audit of medicines held in the home should include a check of ‘use by dates’. Where necessary up to date supplies of medicines should be obtained. As highlighted in previous inspection reports, staff should receive adult protection training. The home’s Adult Protection policies and procedures should be reviewed and where necessary amended, to reflect any local protocols, contact information and the initial action to be taken (things to do and things not to do) if an allegation of abuse arises. As highlighted in previous inspection reports, the first floor bathroom should be refitted to better meet the needs of people with physical impairments. The financial implications associated with this need to be considered within any business plans and budgetary arrangements for the continued running of the home. Staff records should be reviewed to ensure that appropriate records are available and held in the home. As highlighted in the previous inspection report, quality assurance systems should be reviewed to ensure any issues arising are addressed in a timelier manner. As highlighted in previous inspection reports, until recently Milbury Care Services Limited had a local administrative base, however this has moved to Sheffield. To provide sufficient administrative support to the home, comply with data protection legislation and reduce difficulties and delays experienced with forwarding paper work, the home should acquire IT equipment and utilise electronically communicated alternatives. 6. YA27 7. 8. 9. YA34 YA39 YA43 Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Woodham Grange DS0000007523.V294139.R01.S.doc Version 5.2 Page 29 - 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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