Inspection on 01/03/05 for Woodhouse

Care Homes For Adults (18 ­ 65)WoodhouseWigton Crescent Southmead Bristol BS10 6DSUnannounced Inspection1st March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Woodhouse Address Wigton Crescent, Southmead, Bristol, BS10 6DS Email address Tel No: 0117 958 1160 Fax No: 0117 958 1162Name of registered provider(s)/company (if applicable) Shaw Healthcare (Specialist Services ) Ltd Name of registered manager (if applicable) Posiotion Vacant Type of registration Care Home No. of places registered (if applicable) 16Category(ies) of registration, with (number of places) Learning disability (16) Registration number D050001011 Date first registered 29th July 2003 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply? Date of last inspectionDate of latest registration certificate 28th June 2004 NO YES 17/08/04 If Yes refer to Part CWoodhousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 31st March 2005 09:30 am Vanessa CarterID Code135378Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMs Tracy Davis-Jones Area Manager Shaw TrustWoodhousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementWoodhousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Woodhouse. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.WoodhousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Wood House Residential Care Home is registered with the Commission for Social Care Inspection to provide accommodation and personal care for sixteen persons with a learning disability aged 18 to 65 years. A variation has been agreed to provide care for one named person aged over 65 years. When this person leaves the age range will revert back to sixteen persons aged 18 to 65 years. Wood House is a purpose built facility, first registered in July 2003 and situated in the Southmead residential suburb of North Bristol. The accommodation is arranged over two floors, and a passenger lift is installed. Individual accommodation is provided in eight apartments on one side of the building, and eight flats on the other side of the building. The accommodation is linked by the communal facilities on the ground floor. The apartments have en-suite bathroom/toilet facilities, a large living area, and optional kitchen facilities. The flats consist of a lounge, bedroom, kitchen and bathroom facilities. The accommodation located on the ground floor has small patio gardens. The home currently has three vacancies ­ 1 flat and 2 studio apartments. The registered manager has recently resigned from his post and these will not be filled until stability has returned to the staff team.WoodhousePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Brief Introduction This is the first visit to the home by this Inspector. The home manager has very recently resigned from the post, therefore the Area Manager Ms Tracy Davis-Jones has stepped in to hold the fort. The post is due to be advertised within the next week along with an intensive recruitment campaign for support workers. The home currently has a high percentage of agency staff however consistency is maintained by using the same staff. The interaction between staff and services users was noted to be very good. The service users looked well cared for and contented. The Inspector noted several events where the staff had to deal with challenging behaviour and they did this in a quiet, respectful and professional way. The staff team must be commended in the work they do. Choice of Home (Standards 1-5) 2 of 2 standards assessed were met The home scored three for each of the other standards at the inspection in August 2004. The statement of purpose and service users guide contain all the required information to enable a prospective person to know what the service will be like if they come to live at Wood House. The home provides specialist placement for persons with a primary learning disability, but also a range of other needs, including dementia, challenging behaviour, older age and physical impairment. Individual Needs and Choices (Standards 6-10) 5 of 5 standards assessed were met Care planning documentation is available for each service user that covers all aspects of personal, social and health care needs. The plans are person-centred and individualised. An individual support programme is developed with each person. One to one support is arranged for each person throughout the waking day. The service users are encouraged to make choices and to make decisions for themselves. Lifestyle (Standards 11-17) 1 of 1 standards assessed were met The home scored three in all other standards in August 2004. Each person at Wood House has an individual plan of care and is provided with 1 : 1 support. Half of the service users live in self-contained flats with full kitchen facilities. These service users are assisted to develop independent living skills. Each service user has a different level of ability. Those service users living in the studio apartments can be supported to develop new skills. Personal and Healthcare Support (Standards 18-21) 1 of 1 standards assessed were met The home scored three in all other standards in August 2004. The care planning documentation and observations made during the inspection evidenced that the service users at Wood House, are cared for by the support workers, in a respectful and sensitive manner. The staff members were seen to be interacting with the service users Woodhouse Page 6 appropriately. Concerns, Complaints and Protection (Standards 22-23) 2of 2 standards assessed were met The complaints procedure is displayed within the home and contains the details for contacting the Commission for Social Care Inspection. The home has policies and procedures for the protection of adults from abuse, but this was not seen on this inspection. The home needs to improve the standard of record keeping in respect of accident and incident reporting to ensure transparency. Environment (Standards 24-30) 6 of 6 standards assessed were met The home is well designed for the purposes of a care home and is well maintained and decorated throughout. It has a modern and airy feel and was free from any odours throughout. Parts of the home had a noticeable absence of furniture however this is due to damage being incurred by some of the service users. The area manager is completing a furniture audit in order to organise replacement of robust furniture that will be appropriate and more robust. The individual flats and apartments are spacious and have been individualised by the occupants. Staffing (Standards 31-36) 5 of 5 standards assessed were met The staff are aware of their roles and responsibilities and have undergone a range of training to enable them to meet the care needs of the service users. The Inspector observed the staff group being enthusiastic and committed to their work, The home has a robust recruitment process to ensure that the right type of support worker is employed. The staff need to provide a high level of care for service users with complex and challenging needs. The home currently needs to have an intensive recruitment drive in order to stabilise the workforce. Conduct and Management of the Home (Standards 37-43) 1 of 3 standards assessed were met The home manager has very recently resigned from his post. The home is also without a deputy manager. An administrator has recently been employed however this position had been vacant for a period of six months. The home needs to stabilise the workforce however the Area Manager has currently undertaken this role to see it through this unsettling period. The home must improve the standard of record keeping in respect of accident and incident reporting. These standards will need to be inspected in greater detail at the next inspection.WoodhousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 2 16.2(c) YA26 To provide cushions on the sofa in the residents rooms and in the communal lounge 30.09.04Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 3 YA35 To include in the statutory training programme modules of anti-racism and equal opportunity training.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). May accommodate up to 16 persons aged 18-65 years May accommodate one named person with a learning disability aged over 65 years. Registration will revert to 18-65 years when this named person leaves.MET (YES/NO) YES YESWoodhousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 16(2)c YA24 The home is required to provide adequate furniture to meet the needs of the service users. This needs to be robust in order to withstand the challenges it may face The home must appoint a home manager as soon as is practicable and apply to the Commission for Social Care Inspection for registration for this person. The home must maintain accident/incident records appropriately, and record details of any investigation and follow up actions taken The Trust to supply the Commission for Social Care Inspection with a brief summary of financial viability. By 01.09.0529YA37By 01.09.05317 Schedule4 25(2)YA41From 8.03.05 By 01.05.054YA43RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 YA6 YA34 The staff should sign and date any recordings they make in care planning documentation. Head Office to notify the home of POVA first clearance as well as CRB, in the recruitment process. Page 9Woodhouse * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) Woodhouse YES NO NO YES YES NO YES NO YES NO YES NO YES YES NO NO NO YES NO YES 2 0 0 NO NO YES YES X X 01/03/05 09:30 7.0 Page 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.WoodhousePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras Hairdressing, toiletries, aromatherapy If yes, please state what the extras are 0 Key findings/Evidence Standard met? This standard scored a three at the inspection in August and was not assessed on this occasion. The Area Manager explained that care costs are arranged on an individual basis. Each person has different levels of support, this may be 1:1 or 2:1.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? This standard scored a four at the inspection in August and was not assessed on this occasion. The homes most recent admission into the home took up residence in December 2004 ­ this persons care planning documentation was inspected and will be referred to in standard six.WoodhousePage 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard scored a three at the inspection in August and was not assessed on this occasion. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The Area Manager talked about the most recent admission into home. This person had a fairly quick transition to the home as the existing placement was not meeting needs. Trial visits could be arranged for a prospective new service user.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? All current service users are social service or health authority funded, and placements have been made by a number of councils. The Inspector was shown the contracts, called schedule 1s for each service user.WoodhousePage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? The Inspector looked at three sets of care planning documentation, including that of a recently admitted person. The plans provide an individual support programme for each person. Support guidelines are recorded to enable the support staff to know the exact level of needs of the person and the behavioural challenges that may occur. For the newly admitted service user, the home has yet, not determined needs in one specific area so had recorded at present we are unsure how ......... may choose to express themselves in this area. This is good practice and evidences that the home has a holistic and person centred approach to each service user. The plan for this same person had additional information recorded as the staff had identified needs and best practice guidelines. These should be dated and signed for, by the person making the entry. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? During the inspection the Inspector was able to observe each person being treated as an individual. Each of the service users has highly complex needs with challenging behavioural and communication needs. The Inspector saw the service users moving around the home as they wished and also witnessed how the staff handled a situation when a service user became extremely agitated because of staff allocation for the late shift. Seven service users live in the flats and are therefore assisted in a more independent life style. They have their own living space, complete with kitchen and bathroom.WoodhousePage 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The care planning documentation evidenced that the home will encourage all service users to participate in the day to day running of the home, to within their level of ability, despite each person having a very high level of complex needs, it is the homes ethos that the service users should be encouraged to reach their full potential. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Risk assessments are completed as part of the assessment and care planning process. The risk assessments contain detailed guidance for staff to follow and this is in line with good practice. Examples seen concerned, mobility, the risks of seizures, behavioural trigger factors, absconding and issues around eating.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The home has a policy on confidentiality however this was not seen during this inspection. The information regarding service users is kept securely in the managers office or staff room. These rooms are both locked when unoccupied. The Inspector observed the staff handover report at the end of one shift and beginning of another. Information was shared between the workers and all relevant information reported to enable the care staff to undertake their duty in an informed manner.WoodhousePage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Each person at Wood House has an individual plan of care and is provided with 1 : 1 support. Half of the service users live in self contained flats with full kitchen facilities. These service users are assisted to develop independent living skills and the manager explained that each service user has a different level of ability. In addition the home has a communal life skills room and those service users living in the studio apartments can be supported to develop new skills. The care planning documentation evidenced that each service user is enabled to go out into the community and use facilities such as the shops and the swimming pool. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? During this inspection the Inspector was made aware that some of the service users attend local authority day resource centres and college. The standard was not fully assessed but scored a three at the last inspection in August 2004.Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? The standard was not fully assessed but scored a three at the last inspection in August 2004.WoodhousePage 16 Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 0 Key findings/Evidence Standard met? The standard was not fully assessed but scored a four at the last inspection in August 2004.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? The standard was not fully assessed but scored a four at the last inspection in August 2004.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? The standard was not fully assessed but scored a three at the last inspection in August 2004.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? The standard was not assessed as part of this inspection and will be a focus of the next inspection.WoodhousePage 17 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? A minimum of 1:1 support is provided for each person. A separate file had been developed for each resident providing detailed guidance for staff in relation to the residents preferred wishes in relating to personal care provision ­ called Support Guidelines. This is consistent with good practice. The Inspector observed staff members interacting sensitively with the residents, and noted residents were given personal space where appropriate. One person was being allowed to wander in safety with the support worker interjecting when necessary. The Inspector observed the staff handover process and staff members were able to demonstrate a detailed understanding of the needs and preferences of the residents they were supporting. One of the team leaders explained the reasons behind the staff : service user allocation and encouraged the staff to persevere despite an initial confrontational situation. As explained the persons outburst soon settled down. The team leader explained that the actions had in no way infringed that persons rights, rather was a means of introducing another worker who would know their needs. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) XX0 Key findings/Evidence Standard met? The standard was not assessed as part of this inspection and will be a focus of the next inspection. One person has recently been seen in the accident and emergency department having been taken ill whilst out with support staff ­ the staff responded appropriately to this medical emergency. A score of three was made in August 2004. Woodhouse Page 18 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? The standard was not assessed as part of this inspection and will be a focus of the next inspection. A score of three was made in August 2004.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard scored a three at the inspection in August and was not assessed on this occasion.WoodhousePage 19 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 X 3 Key findings/Evidence Standard met? The home has a Shaw Trust Complaints Procedure. This is displayed in the home and included in the Statement of Purpose. The procedure needs to state the timescale within which the complaint will be dealt with. Details regarding the Commission for Social Care Inspection are included. In the last year, the home has not received any complaints. The Inspector did not speak with any of the service users regarding how they felt about raising any concerns with the manager or support staff, however did hear at least two service users vocalising when they were unhappy.WoodhousePage 20 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? The policy and procedure file was located in the staff office and contained policies to safeguard residents from any form of abuse. The area manager explained that all staff will complete a module about abuse as part of the Learning Disability Award Framework. Also staff will attend statutory training sessions organised by Bristol City Council ­ dates are currently available throughout 2005. The home has a training matrix in order to identify those staff members who need training or refresher courses. The home needs to note the comments I have made in standard 41, regarding the recording of accidents, bruising and minor injuries. The manager must ensure that records are kept of all incidents, that an investigation is undertaken to determine how the injury occurred, and that follow up action and recordings are made. The manager must also ensure that reporting under protection of vulnerable adults procedures are made if this is appropriate. Guidance must be obtained from the local authority if need be.WoodhousePage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is purpose built and modern, having only been opened for approximately 18 months. All areas of the home are accessible to persons using a wheelchair and there is one shaft lift from ground to first floor. The home is bright, airy, and free from offensive odours. The corridors are wide and the whole home has a sense of space. Wood effect flooring has been used throughout the home. Parts of the home however are sparsely furnished and the area manager explained that a significant amount of the ordinary domestic furniture has been damaged. The area manager was due to complete an environmental assessment on the day of inspection but this is now rescheduled. The home needs to be furnished with robust furniture that will stand up to the challenges presented by the service users. A budget has already been allocated for these works. At the previous inspection a requirement was made regarding the sofa chairs being without coverings. This situation has still not been resolved however is to be dealt with along with the re-provision of furniture. It is expected that the home will have complied with the requirement by the next inspection. The maintenance person was working in the home on the day of inspection. He now has storage for the supplies and any equipment ­ a requirement was made in respect of this and has been complied with.WoodhousePage 22 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 16 16 0 0 16 X16 X X X3 Key findings/Evidence Standard met? Individual accommodation exceeds the spatial requirements of the legislation. There are 8 studio apartments with an en-suite bathroom with shower facilities, on one side of the building and 8 self contained flats on the other side, consisting of a lounge, bedroom, bathroom with toilet and wash hand facilities, and a fully fitted kitchen. The Inspector viewed one empty flat, and one empty apartment. The accommodation was of a high standard. In touring the building the Inspector was able to observe that the occupied rooms had all been personalised. The accommodation on the ground floor leads out into individual patio gardens.WoodhousePage 23 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The Inspector did not view all the rooms. Those rooms viewed contained furniture and fittings suitable to meet the needs of the residents. The rooms had been personalised, were homely and comfortable. The Inspector again noted one sofa where the cushions were without protective coverings. The area manager explained the cushions had been soiled and were being laundered. This will be addressed as part of the furniture audit. The Inspector noted that one person had a double bed ­ it was explained that this person has requested this and its provision had increased their safety at night. Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? All rooms have en-suite facilities consisting of toilet, wash hand basin and bath. Shower facilities are sited above each bath. The area manager explained the facilities could be changed according to individual need. A communal bathroom is available with assisted bathing facilities. Communal toilets are located near to the dining area. In addition the home has a hot tub.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The communal space consists of three lounges, a social skills kitchen and two therapy rooms. The keep fit room is likely to be changed into a sensory room ­ progress regarding this will be checked at the next inspection. The home is also planning to use one of the meeting rooms as a media room. Laundry facilities are provided, are domestic in style and consist of one washing machine that will complete a sluice cycle and a tumble dryer. Service users can use the equipment under staff supervision. The two lounges on the ground floor are both sparsely furnished. This will be addressed as part of the furniture audit.WoodhousePage 24 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? The Inspector observed an abundance of disability equipment throughout the home. Grab rails, specialist bathing equipment and a passenger lift are installed. A full assessment was not made during this inspection however the home scored three at the inspection in August 2004Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was bright, airy and clean and there were no offensive odours in the home. The home was maintained to a high level of cleanliness. The storage of all cleaning materials was as recommended by Control of Substances Hazardous to Health (COSHH) guidelines and since the last inspection, records verified that the domestic staff have received COSHH training. Support staff are provided with any necessary protective clothing (for example plastic gloves and aprons) they may need in order to carry out their duties. The Inspector was aware that the home had run out of provisions however the team leader had the situation in hand and was arranging for the purchase of a temporary stock until the normal delivery is made. The home has a copy of the Avon Health Authority Infection Control Guidelines.WoodhousePage 25 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? The Inspector saw that support workers have a job description that outlines their role and records that they report to the team leader. The document states they are to promote a caring environment through high standards of professional practice ensuring effective use of resources. Observations made by the Inspector during the course of the inspection were that the staff demonstrated this commitment. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The home is currently running with several support vacancies and there is a high use of agency cover. The manager explained that block bookings are made and the same staff work at the home, ensuring consistency of care for the service users. An intensive recruitment drive is planned in order to stabilise the workforce. The Inspector looked at the staff training files and evidenced that relevant training has been undertaken to ensure that a wide range of skilled staff are available who are competent to meet the needs of the service users. Examples of training undertaken are as follows: Medication Handling course Positive Behaviour Management First Aid Epilepsy awareness Basic Food Hygiene Personal Response Training Health and Safety and COSHH Brain Injury The home has an induction training programme for new staff members, followed by the Learning Disability Award Framework (LDAF). It is an expectation that all new recruits will be signed up to do the NVQ Level 2 course within six months of employment. This is good practice and demonstrates a commitment by the organisation to develop the staffs full potential and provide a good service.WoodhousePage 26 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 13 0 0 X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing 0 0 0XX3 Key findings/Evidence Standard met? The home is staffed with support workers and team leaders. The home currently has three qualified team leaders (2 x RNLD and 1 x RMN) plus one unqualified team leader. The service users all have differing, highly complex care needs and require a minimum of 1:1 staff allocation. Therefore each shift is covered by between 13-15 staff members. In addition, some of the service users are funded for day care hours. The home employs separate domestic and catering staff.WoodhousePage 27 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The home has a robust recruitment policy. An application pack is issued to all interested applicants. This contains a letter from the chief executive of the trust, an application form, including details of previous employment and a section marked why I want the job. New recruits must name three people to act as referees, must complete a medical questionnaire and a declaration of criminal records. A job description is issued. The area manager explained that interviewing is undertaken by two managers, following equal opportunity guidelines. The area manager explained that CRB and POVA first clearance is obtained for all new recruits and duties cannot commence until this is obtained. The home keeps copies of the application form, references and proof of identity and the head office will send out confirmation of CRB clearance. This was verified during the inspection. It is required that the head office also send confirmation of POVA first clearance and the area manager will discuss this at the next management meeting. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The training plan for 2005 consists of: Person Centred Planning Intensive Interaction Confidentiality Core Values NVQ in Cleaning and Support D32 and D33 (NVQ Assessor Training) All new recruits will undertake a statutory 4 day induction programme. The content of this was not discussed at this inspection however, the previous inspector looked at this in detail ­ no changes have been made to its content. Following completion of the induction programme, support workers will undertake the Learning Disability Award Framework. The Inspector spoke with one support worker who had already completed level 1 and 2 and was hoping to start 3 and 4. It was recommended following the last inspection that the home arrange equal opportunity and anti-racism training ­ this has yet to be addressed. The area manager will ensure this is discussed with the trust training co-ordinator.WoodhousePage 28 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this inspection, but scored three in the inspection in August 2004. The recent departure of the registered home manager has highlighted the fact that staff supervision had slipped for many months. The area manager has already begun a programme of staff supervision and had several sessions planned for the day of inspection. The Inspector spoke with one staff member who valued the sessions and was pleased they had been re-instigated. This standard will be a focus of the next inspection.WoodhousePage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO1 Key findings/Evidence Standard met? The home registered manager resigned from the post the previous week ­ the area manager will ensure that notification is made to the Commission for Social Care Inspection. Since the inspection this has been received. The area manager is holding the fort at the moment and the process of recruitment will hopefully commence next week, with an advertisement placed in the RCN publication. The home is also without a deputy manager. An administrator has been recently appointed however the post had been vacant for six months. The home needs to undergo an intensive recruitment process in order to stabilise the workforce. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? It was not possible to assess this standard on this inspection because of the recent resignation of the home manager. The home previously scored three in August 2004. This will be a focus of the next inspection.WoodhousePage 30 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, and will be a focus of the next inspection. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The organisation has policies and procedures that comply with current legislation and are reviewed regularly by Shaw Trust to reflect the National Minimum Standards.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The Inspector reviewed the care planning documentation and other relevant information kept concerning the service users. The care files were up to date, detailed and in good order. Staff files were also well maintained and contained all those items as listed in schedule 2. The inspector examined the fire safety records ­ these were in order and showed that all equipment was regularly checked. Although the home has organised many fire drills it was not possible to evidence that all staff had been appropriately instructed in fire safety training. The maintenance of accident records was extremely poor. The Inspector looked at the records of recent accidents or incidents and noted that there was no evidence of any followup action being taken. The home manager had signed off the forms and they had been filed away. This is unacceptable practice. The Inspector was also concerned to see a Body Map Record. On one persons sheet, staff members had added in at different times where bruising or red areas were noted. There was no record of any investigations into how these injuries may have been sustained. A discussion took place with the area manager. These forms are being used inappropriately and were only to be used to record skin condition upon admission into the home or following a break away from the home (i.e. hospital admission). It is required that the home immediately cease this practice and use appropriate reporting methods when bruising for example is noted. When incidents or accidents like this occur, the manager is expected to carry out an investigation, and the Inspector will expect to see evidence of such.WoodhousePage 31 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? The home has previously scored three in this standard and it was not assessed on this inspection.Standard 43 (43.1 ­ 43.7) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met? The Area Manager has been asked to supply the Commission for Social Care Inspection with a brief summary of the financial viability of the home.WoodhousePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance May accommodate up to 16 persons aged 18 to 65 years CommentsYESYES Condition Compliance May accommodate up to one named person with a learning disability aged over 65 years. Registration will revert to 18 to 65 years when this named person leaves. CommentsCondition CommentsComplianceLead Inspector Second InspectorVanessa CarterSignature Signature SignatureRegulation Manager Michael Miles Date 11 April 2005Public reports It should be noted that all CSCI inspection reports are public documents.WoodhousePage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.Please limit your comments to one side of A4 if possible The Acting Manager and staff at Woodhouse would like to thank the Inspector for their guidance and support during the inspection process.Action taken by the CSCI in response to provider comments: Woodhouse Page 34 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 A written Action Plan, which indicates how requirements are to be addressed and stating a clear timescale for completion, has been received and will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOWoodhousePage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, P J Nixey of Shaw Healthcare (Specialist Services) Ltd, confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Chief Executive 8 April 2005 P J NIxeyWoodhousePage 36 Woodhouse / 1st March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000044679.V212263.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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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