Inspection on 12/03/04 for Woodhouse

Care Homes For Adults (18 ­ 65)WoodhouseWigton Crescent Southmead Bristol BS10 6DSUnannounced Inspection12th March 2004 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: 01179581160 Fax No: TBAName of registered provider(s)/Company (if applicable) Shaw healthcare (Specialist Services) Ltd. Name of registered manager (if applicable) Robert Theobald 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 5th January 2004 No YES 17.12.03 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 316th February 2004 09:30 am Paul Grey Lyn DavisID Code109177Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionWoodhousePage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. 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: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementWoodhousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) 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 NCSC in respect of Woodhouse. The inspection findings relate to the National Minimum Standards (NMS) for Care Home 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 NCSC 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 · Report of the Lay Assessor (where relevant) · 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 and the Children Act 1989 as amended. 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. Woodhouse Residential Care Home is registered with the National Care Standards Commission to provide accommodation and personal care for 16 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 16 persons aged 18 to 65 years. Woodhouse is a new purpose built facility registered in July 2003 and situated in a residential suburb of Bristol. The accommodation is arranged over two floors, and a passenger lift is installed. Each apartment has en-suite bathroom/toilet facilities, a large living area, and optional kitchen facilities. The ground floor apartments have access to small individual courtyard areas via patio doors from the living rooms. The communal space consists of two small lounges, one large dining/lounge area, a life skills kitchen, therapy room, hot tub room, and a small communal garden. The home is situated in close proximity to local shops and amenities, and major bus routes are nearby.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 Choice of Home (Standards 1-5) 1 of 1 standards assessed were met. Documentation confirms that a full assessment of the service users needs is undertaken prior to admission and individual plans of care are developed form this assessment. The new manager was able to confirm this process will continue. Current care planning is thorough and up to date. Individual Needs and Choices (Standards 6-10) 2 of 3 standards assessed were met Information in the care plans reflects the service users choices and right to make decisions. The staff team involve service users in all aspects of decision-making about their care. Woodside strives to support service users maintaining friendships and social activities outside of Woodside. The recording system developed by the administrator was clear and effective, and all records were up to date and in order. Service users input into the running of Woodhouse is currently achieved via negotiation and care planning. Service users have no specific forum to effect policies, procedures or day-today running of Woodhouse. Woodhouse maintains high staffing ratios to allow staff to support service users both in and outside of Woodhouse. The risk assessments contained detailed guidance for staff and had been reviewed on a regular basis. The process begins when residents visit on a trial basis. Staff and the manager appeared well motivated to encourage and support service users in their understanding and management of risk. Lifestyle (Standards 11-17) 2 of 2 standards assessed were met. Service users are enrolled at college if they desire, and sufficient staff are allocated per shift to allow service users staff escort as necessary Woodhouse has an active range of leisure activities for service users. Woodhouse Page 6 Of particular note was the emphasis on normalised social activities as opposed to more institutional group trips. The environment lends its self well to activities such as service users cooking a meal and inviting a friend or other service user to their flat to eat it. Service users are encouraged to use local facilities, the local pub, go shopping with staff, (the manager explained to inspectors that sufficient staff will be made available where necessary to enable such activities). Woodhouse has a large spa bath recently adapted for able bodied and service users in wheel chairs, in addition to smaller domestic spa baths in each individual flat. Personal and Healthcare Support (Standards 18-21) 0 of 2 standards assessed were met Medication is administered via a Boots system. Medication was safely and appropriately stored, the documentation suggests it has been correctly administered and stock levels appeared appropriate. However, the inspector noted evidence that medication administration training had been cascaded down from trained staff and was not provided by a nationall accredited provider was not via a nationally accredited route but rather has been cascaded down by trained staff members. This practice must stop. The Inspector notes that Boots medication training will occur on the 6th of April. At the time of inspection National Minimum Standards were not met. The inspector noted that 4 of 5 care files sampled did not contain sufficient information in respect of residents wishes in the event of death. It is required that this should be remedied. Concerns, Complaints and Protection (Standards 22-23) 0 of 0 standards assessed were met Environment (Standards 24-30) 5 of 5 standards assessed were met The home is purpose built with each service user having an individual flat and access to extensive communal facilities. The inspector noted the overall environment was exceptional in terms of facilities, communal space and individual living areas, (flats). The home was bright, airy, and free from offensive odours. Wooden laminate type flooring has been used throughout the home. The furniture provided was domestic in character and of good quality. The Inspector noted that individual accommodation exceeded the space requirements of the legislation. Each room had en-suite bathroom or shower facilities, depending on individual need. Each room had the option of the provision of kitchen facilities depending on individual choice, and provided through a risk assessment framework. This was good practice. Woodhouse Page 7 Individual accommodation was of a very high standard. Staffing (Standards 31-36) 4 of 4 standards assessed were met Inspection of the duty rota, observation and discussion with staff and residents confirmed Woodhouse achieved a minimum of one staff member per service user in the daytime to one staff member per service user at nights. The inspector found that staff understood their role within the home, and were sensitive to the needs of the residents. Conduct and Management of the Home (Standards 37-43) 2 of 2 standards assessed were met The new manager has been is recently appointed, has the Registered Managers Award, and is a qualified Learning Disabilities Nurse. Documentary evidence of this was not checked on this unannounced inspection. The insurance certificate and certificate of registration were on display on entry to Woodside. The inspector noted the certificate of Registration had been altered by hand to reflect the previous change of manager. All records reviewed during the course of the inspection were up to date and in order. The Inspector noted the filing system in the office was well organised, and documentation was easy to locate.WoodhousePage 8 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. No. Regulation Standard Required actions Timescale for action 1 2 12.3 23.2 YA2 YA24 To include in the care plans the service users wishes in the event of death To review the communal garden and ensure it is safe and suitable for use by all persons accommodated To review the system of administration of medication and ensure all records are up to date and provide staff training if appropriate. 30th of March 30th of June 30th of January313.2 Sch.3 YA3Action is being taken by the National Care Standards Commission 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 StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)WoodhousePage 9 WoodhousePage 10 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 and recommendations 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, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 12.3 YA21 To provide evidence that the home has endeavoured to obtain service users wishes in the event of their death and update care plans appropriately. Immediate223.2YA24To review the communal garden, and policies 30th of and procedures to ensure it is safe and June suitable for use by all persons accommodated To remedy the trip hazard between the garden paving slabs. It is required that training for administration of medication is conducted by a nationally accredited body. Immediate 30th of April323.2 13 18YA244YA20RECOMMENDATIONS 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) No. Refer to Good Practice Recommendations Standard * The inspector recommends a policy be drafted and implemented concerning the safe use of the garden for service users, with staff support. Consideration a wheelchair friendly area is also made.1YA24WoodhousePage 11 * 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: YES YES NO YES NO NO YES NA NO NO YES NO YES YES NO NO NO YES NO YESWoodhousePage 12 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)4 X X NO NO YES NO X X 11/03/04 09:30 3The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards 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 13 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, 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 2190 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, on the previous inspection it met National Minimum Standards.WoodhousePage 14 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. 3 Key findings/Evidence Standard met? The Inspector reviewed the care files and found evidence of local authority assessments. Documentary evidence confirms a full assessment of need is undertaken prior to admission and individual plans are developed form this assessment. The new manager was able to confirm this process will continue. The inspector notes current care planning to be thorough and up to date but somewhat cumbersome and not user friendly for employees or service users.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 was not assessed on this inspection, on the previous inspection it met National Minimum Standards.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. 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, on the previous inspection it met National Minimum Standards.WoodhousePage 15 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. 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsWoodhousePage 16 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. 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, on the previous inspection it met National Minimum Standards. The inspector noted home operates a key worker system and one to one support is available throughout the waking day. The Inspector noted that the statement of purpose reflects the high level of support offered in the home.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? Woodhouse accommodates people with complex communication and behavioural needs. Information in the care plans reflects the service users choices and right to make decisions. Evidence that the staff team involved service users in all aspects of decision making about their care where possible was noted in the care planning notes. During the inspection the manager informed inspectors that Woodside strives to support service users maintaining friendships and social activities outside of Woodside. The recording system developed by the administrator was clear and effective, and all records were up to date and in order. The inspector noted service users maintain their own benefit books where possible and that this is limited only by the assessment and care planning process.WoodhousePage 17 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. 2 Key findings/Evidence Standard met? Service users input into the running of Woodhouse is currently achieved via negotiation and care planning. Service users have no specific forum to effect policies, procedures or day to day running of Woodhouse. The manager will implement regular community meetings by 19.6.04 to give service users opportunity to have a say in the day to day running of Woodhouse.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? High staffing ratios allow staff members to support service users to maximise their involvement in any decision making or risk assessment processes. Detailed risk assessments had been developed from the assessment process. The Inspector noted that actions required had been implemented in relation to adaptations to the environment. For example grab rails being fitted to a residents toilet area to improve independence. The risk assessments contained detailed guidance for staff and had been reviewed on a regular basis. The manager explained the risk assessment process began when residents visited on a trial basis. The transition period was fundamental to the risk assessment process. This was good practice Staff and the manager appeared well motivated to encourage and support service users in their understanding and management of risk. 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. 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsWoodhousePage 18 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. 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsStandard 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 3 Key findings/Evidence Standard met? The manager informed the inspector that the staff team are actively helping service users find appropriate employment. Service users are enrolled at college if they desire, and sufficient staff are allocated per shift to allow service users staff escort as necessary. Where able service users hold their own benefit books and staff help service users with any problems arising.WoodhousePage 19 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? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsStandard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. Key findings/Evidence Standard met? Woodhouse has an active range of leisure activities for service users.4Of particular note was the emphasis on normalised social activities as opposed to more institutional group trips. The environment lends its self well to activities such as service users cooking a meal and inviting a friend or other service user to their flat to eat it. Service users are encouraged to use local facilities, the local pub, go shopping with staff, (the manager explained to inspectors that sufficient staff will be made available where necessary to enable such activities). The staff team are currently in the process of organising drama therapy in the near future. The inspector noted in particular the good practice of enabling service users to have an individualised social activity with and without staff support as opposed to the more commonly used practice of group activities. Woodhouse has a large spa bath recently adapted for able bodied and service users in wheel chairs, in addition to smaller domestic spa baths in each individual flat. 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? This standard was not assessed on this inspection; on the previous inspection it met National Minimum Standards.WoodhousePage 20 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? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsStandard 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? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsWoodhousePage 21 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 procedure 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. 0 Key findings/Evidence Standard met? Nursing care is not provided at Woodhouse.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? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsWoodhousePage 22 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. 2 Key findings/Evidence Standard met? Medication is administered via a Boots system. Medication was safely and appropriately stored, the documentation suggests it has been correctly administered and stock levels appeared appropriate. The staff member with the inspector was able to clearly outline the procedures for safe medication administration. The inspector noted evidence that medication administration training was not via a nationally accredited route, i.e. Boots Training, or training provided by another nationally accredited body. Medication administration training has been cascaded down by trained staff members. This practice must stop. The Inspector notes that Boots medication training will occur on the 6th of April. As the appropriate training is now in place this will not be subject to a requirement by the Commission at this stage. At the time of inspection however National Minimum Standards were not met. The inspector refers in particular to standard 20.9, and 20.10. 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. 2 Key findings/Evidence Standard met? The inspector sampled 5 care files. The inspector noted that 4 of these still did not contain sufficient information in respect of residents wishes in the event of death. The previous Inspector required the manager to review the care file format to include the residents wishes in the event of death, where possible and to include in the care file the name of the legal executor if no family members were involved. The inspector requires this be addressed.WoodhousePage 23 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 times-scales 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 NCSC Percentage of complaints responded to within 28 days X X X X X X X 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsWoodhousePage 24 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 YESX0 Key findings/Evidence Standard met? This standard was not assessed on this inspection; on the previous inspection it met National Minimum Standards.WoodhousePage 25 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 was bright, airy, and free from offensive odours. Wooden laminate type flooring has been used throughout the home. The furniture provided was domestic in character and of good quality. The home is purpose built with each service user having an individual flat and access to extensive communal facilities. The inspector noted the overall environment was exceptional in terms of facilities, communal space and individual living areas, (flats). The inspector notes the garden has a degree of slope toward the rear of the building but recognises the practical constraints involved in either levelling this area and the consequent extensive costs of construction. The inspector noted gaps between the paving slabs on the grass constitute a trip hazard for staff and service users. The inspector requires this be addressed and that the registered manager informs the commission in writing once completed.WoodhousePage 26 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 8 8 0 0 8 08 0 0 04 Key findings/Evidence Standard met? The Inspector noted that individual accommodation exceeded the space requirements of the legislation. Each room had en-suite bathroom or shower facilities, depending on individual need. A toilet and wash hand basin were also provided. Each room had the option of the provision of kitchen facilities depending on individual choice, and provided through a risk assessment framework. This was good practice. Individual accommodation was of a very high standard.WoodhousePage 27 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 rooms on the day of inspection. Those rooms viewed contained furniture and fittings suitable to meet the needs of the residents. The rooms had been personalised, and were homely and comfortableStandard 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. 4 Key findings/Evidence Standard met? All rooms have en-suite facilities consisting of toilet, wash hand basin and bath. There is an option to provide kitchen facilities in all rooms. A communal bathroom is available with assisted bathing facilities, in addition to a luxurious spa bath. Additional communal toilets are located near to the dining area. 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? Woodhouse has extensive communal space consisting of three lounges, a social skills kitchen and two therapy rooms. Laundry facilities are provided and are domestic in style. All individual rooms on the ground floor have a small courtyard area accessible from a patio door in the room. The home has a no smoking policy and residents who smoke do so outside or in the privacy of their own rooms supported by staff.WoodhousePage 28 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? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsStandard 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 inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection. The inspector noted the home was clean and free from offensive odours. On the previous inspection it met National Minimum StandardsWoodhousePage 29 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? Through inspection of the duty rota, observation and discussion with staff and residents, the Inspector noted Woodhouse was meeting their commitment outlined in their statement of purpose. Staffing achieved a minimum of one staff member per service user in the daytime to one staff member per service user at nights. The inspector found that staff understood their role within the home, and were sensitive to the needs of the residents. The Inspector observed the staff using their knowledge and skills to communicate effectively with the residents. Those residents spoken with told the Inspector the staff team were always helpful.WoodhousePage 30 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. 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 X X X 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 X X XXX0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsWoodhousePage 31 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. 3 Key findings/Evidence Standard met? Documentary evidence indicates a comprehensive induction and training programme. The manager informed the inspector that training will incorporate the Learning disabilities Award Framework. This training will be compulsory for all staff working in the home. Positive Response Training has been cascaded down to staff by the previous manager. The care plans showed that each resident required one to one support, and staffing levels would not be sufficient if care staff were undertaking tasks in the kitchen when the cook was not on duty. The manager informed the inspector that additional staff had been recruited to cover this shortfall. 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 Inspector reviewed 4 employee files. Staffing information contained passports, references. Evidence of CRB checks being applied for was in place. Some information was held at head office and the manager was in the process of reviewing the staffing information files. The Inspector found evidence of job descriptions and birth certificates. The inspector noted some references still contained limited information. 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? Shaw offer a clearly organised training package. The new manager has posted this schedule up in the office. The inspector noted training on offer consisted of; Policies and Procedures, Induction Training, PRT, Manual Handling, aetiology of learning disabilities, Beliefs and values, Challenging Behaviour, Management strategies for challenging behaviour, continence training, Sensory impairment, Healthy eating, PICA, Epilepsy Training, Rectal diazepam training, Boots system training, First Aid, Food Hygiene, Health and Safety.WoodhousePage 32 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 assessed on this inspection, on the previous inspection it met National Minimum StandardsWoodhousePage 33 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 or equivalent. YES3 Key findings/Evidence Standard met? The new manager has been is recently appointed, has the Registered Managers Award, and is a qualified Learning Disabilities Nurse. Documentary evidence of this was not checked on this unannounced inspection. The insurance certificate and certificate of registration were on display on entry to Woodside. The inspector noted the certificate of Registration had been altered by hand to reflect the previous change of manager. It is acknowledged that the certificate was out of date in that the previous managers are no longer responcible for the home. However Registration documents are legal documents and can only be changed by the registering authority.A new certificate will be issued to accurately reflect the name of the current manager following a successful application for registration.WoodhousePage 34 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? This standard was not assessed on this inspection, on the previous inspection it exceeded National Minimum StandardsStandard 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 during this inspection. Due to the infancy of the service and the recent appointment the new manager. Shaw conduct annual audits of the home and the financesStandards 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 Younger Adults. 0 Key findings/Evidence Standard met? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsWoodhousePage 35 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. 0 Key findings/Evidence Standard met ? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsStandard 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. 3 Key findings/Evidence Standard met? All records reviewed during the course of the inspection were up to date and in order. The Inspector noted the filing system in the office was well organised, and documentation was easy to locate.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 ? This standard was not assessed on this inspection, on the previous inspection it met National Minimum StandardsWoodhousePage 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DatePaul Grey Lyn Davis 25/06/03Signature Signature SignatureWoodhousePage 37 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsNASignatureIt should be noted that all NCSC inspection reports are public documents.WoodhousePage 38 PART EE.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 possibleAction taken by the NCSC in response to provider comments: Woodhouse Page 39 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 accurateNONOYESNote: 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. E.2 Please provide the Commission with a written Action Plan by 14th June 2004 which indicates how requirements are to be addressed and stating a clear timescale for completion. This 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 WoodhousePage 40 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of 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 Or E.3.2 I of am unable to 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) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.WoodhousePage 41 - 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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