Inspection on 08/12/05 for Woodham Lodge

This inspection was carried out on 8th December 2005.

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

The inspector found 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

Woodham Lodge 12/01/09

Woodham Lodge 24/01/07

Woodham Lodge 21/01/05

Woodham Lodge 30/06/04

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 Lodge Burn Lane Newton Aycliffe Durham DL5 4PJ Lead Inspector Mr Paul Emmerson Unannounced Inspection 8 December 2005 11:00 Woodham Lodge DS0000007525.V267742.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 Woodham Lodge DS0000007525.V267742.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. Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodham Lodge Address Burn Lane Newton Aycliffe Durham DL5 4PJ 01325 319899 01325 319899 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) Milbury Care Services Limited Mrs Carol Brittain Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate a named individual as set out in a letter to the registered person dated 30th October, 2003 which establishes the basis on which the individual`s needs will be met by the home. Where necessary the home`s Statement of Purpose shall reflect any changes in service provision required for this arrangement. This condition may not apply to anyone else, other than the named individual, who falls outside the registered category. 21 July 2005 Date of last inspection Brief Description of the Service: Woodham Lodge is a large converted and extended bungalow, which is situated in its own grounds and is owned by Milbury Care Services Limited. The home is registered to provide care for up to 6 adults who have learning disabilities, 1 of whom is over 65, in four single and one double bedrooms. The home is in the Woodham area of Newton Aycliffe, within walking distance of the town centre and local amenities. Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. By law we have to inspect all care homes at least twice a year. This unannounced inspection was carried out in accordance with this obligation. The inspection took place over 6 hours, on the morning and afternoon of Thursday 8 December 2005. In line with current CSCI policy on ‘Proportionality’, the inspection focused upon a number of key standard outcomes for service users. The key standard outcomes not inspected on this occasion were assessed during the last inspection of the home. The inspector looked around the building and a number of records were examined. Within the limits of their communication and understanding, service users were spoken to. The manager, 4 members of staff and 2 physiotherapists visiting the home were also spoken to. On the day of the inspection there were no other visitors to the home. What the service does well: What has improved since the last inspection? To ensure that the home can meet the needs of the people accommodated one of the homes bathrooms has been substantially upgraded. It now has an adjustable height bath, a ceiling track hoist and a changing table. The home’s manager has completed a ‘Registered Managers Award’ training course. Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 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. Woodham Lodge DS0000007525.V267742.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 Woodham Lodge DS0000007525.V267742.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): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. EVIDENCE: NA Woodham Lodge DS0000007525.V267742.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): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. EVIDENCE: NA Woodham Lodge DS0000007525.V267742.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): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. EVIDENCE: NA Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 11 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. 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 care needs. However, they were seen to be well cared for and comfortable in their home. The people who live at Woodham Lodge 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. The inspector observed that staff’s commitment to team-working, and good communication between them, ensures that service users’ personal and health care needs are met. Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 12 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 self-care tasks, thus promoting independence in a dignified and respectful manner. The care plans read by the inspector were seen to document service users’ 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 are also informing the delivery of care within the home. However, it was noted that annual reviews of care are now overdue. To ensure that any changes in service users’ needs are being adequately met, care reviews must be conducted. 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. However, where medicines need to be stored in a refrigerator, at or below a certain minimum temperature, a suitable refrigerator (other than that used to store foodstuffs) should be used. Woodham Lodge DS0000007525.V267742.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 & 23. 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 Milbury Care Services Limited, has detailed complaints and adult protection procedures. Copies of these are available for staff use. Information about complaints, how and who to make them to, is also provided in the home’s ‘Service Users Guide’. House meetings serve as an additional forum to discuss concerns or potential difficulties. Staff interviewed voiced a commitment to the service users they work with and to upholding service users’ rights. However, only some of the staff interviewed had 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, it is recommended that staff receive training specifically covering adult protection and the protection of vulnerable adults. Policy and procedure documents relating to adult protection provide information and guidance to staff. However, a copy of ‘Durham & Darlington Adult Protection Committee’s Inter-Agency Adult Protection Policy & Procedures’ on abuse and the protection of vulnerable adults should also be obtained and be available in the home. The home’s own policies and procedures in this area should then 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. Woodham Lodge DS0000007525.V267742.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): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. However, as highlighted in the previous inspection report, a review of the homes living environment should be carried out to consider any adaptations required to meet the changing needs of the service users accommodated. The financial implications associated with this need to be considered within any business plans and budgetary arrangements for the continued running of the home. EVIDENCE: NA Woodham Lodge DS0000007525.V267742.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): 32, 33, 34 & 35. Sufficient staff are employed. The home has a settled, well-trained and wellled staff team. EVIDENCE: Care is provided by a committed, well-trained staff team. Many of the staff have worked at Woodham Lodge 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. has been provided by Milbury Care Services Limited through its regional training plan. In house instruction, for example to provide physiotherapy, has also been arranged. Although no recent staff appointments have been made, 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. Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 16 Due to the needs of the service users accommodated, the agreed staffing levels for the home require three to four staff to be on duty throughout the waking day. With night staffing arrangements (1 person awake, 1 person asleep) this equates to 422 weekly care hours for the home. Although staffing levels should be kept under review, in particular as service users get older, from discussions with staff, rosters and other documents examined these staffing levels are considered to be adequate to meet the current needs of the people currently accommodated. Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 17 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. Woodham Lodge is well run. However, although quality assurance systems are in place, remedial action to rectify issues raised takes too long. EVIDENCE: The home’s manager has an NVQ (National Vocational Qualification) level 4 in care. She originally trained and qualified as a nurse and also has a Registered Managers Award qualification, which she has recently completed. She provides leadership to the home’s staff team. Staff interviewed spoke of good communication and effective teamwork. 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. Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 18 Milbury Care Services Limited has policies, procedures and systems relating to quality assurance. Regular audit checks are undertaken and forwarded to the regional office. However, previous failings to address outstanding issues rendered the company’s quality assurance systems meaningless. Quality assurance systems should be reviewed to ensure any issues arising are addressed in a more timely manner. Monthly reports required under Regulation 26 of the Care Homes Regulations 2001 are now being provided to CSCI detailing the action being taking to address any shortfalls in the home. Until recently, Milbury Care Services Limited had a local administrative base, however this has moved to Sheffield. To provide sufficient admin’ support to the home, 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 Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 19 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 X X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodham Lodge Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 3 X DS0000007525.V267742.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No 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 YA19 Regulation 15(2)(b) Timescale for action Care reviews must be conducted. 01/03/06 Requirement 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 YA20 Good Practice Recommendations Where medicines need to be stored in a refrigerator, at or below a certain minimum temperature, a suitable refrigerator (other than that used to store foodstuffs) should be used. Staff should receive adult protevtion training. A copy of ‘Durham & Darlington Adult Protection Committee’s InterAgency Adult Protection Policy & Procedures’ on abuse and the protection of vulnerable adults should also be obtained and be available in the home. The home’s own policies and procedures in this area should then 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 the previous inspection report, a review of the homes living environment should be carried out to consider any adaptations required to meet the changing needs of the service users accommodated. DS0000007525.V267742.R01.S.doc Version 5.0 Page 21 2. YA23 3. YA24 Woodham Lodge 4. 5. YA39 YA43 The financial implications associated with this need to be considered within any business plans and budgetary arrangements for the continued running of the home. Quality assurance systems should be reviewed to ensure any issues arising are addressed in a more timely manner. As highlighted in the previous inspection report, until recently Milbury Care Services Limited had a local administrative base, however this has moved to Sheffield. To provide sufficient admin’ support to the home, 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. Woodham Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 22 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 Lodge DS0000007525.V267742.R01.S.doc Version 5.0 Page 23 - 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!