Inspection on 17/08/04 for Woodhouse

Care Homes For Adults (18 ­ 65)WoodhouseWigton Crescent Southmead Bristol BS10 6DSAnnounced Inspection17th and 19th August 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: 01179581162Name of registered provider(s)/company (if applicable) Shaw Healthcare (Specialist Services ) Ltd Name of registered manager (if applicable) Mr 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 28th June 2004 no YES 12/3/04 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 317th August 2004 09:30 am Helen TaylorID Code109177Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr Robert Theobald Registered ManagerWoodhousePage 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. Woodhouse 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. 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. 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.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 IntroductionThe Inspector found a warm, relaxed environment. The Inspector observed the residents making full use of the communal lounge, and individual rooms had been personalised. The staff members present interacted positively with the residents, and were able to demonstrate their understanding of the needs of the persons accommodated. The requirements and recommendations from the previous inspection had all been implemented. Choice of Home (Standards 1-5) 5 of 5 standards assessed were met. A statement of purpose and service user guide has been developed and contains all components required in this standard. The Inspector saw that each resident has a copy of the resident guide in their room. A review of the care files revealed a full assessment of need is undertaken prior to admission and individual plans are developed from this. Local Authority assessments were also used in this process. The care files contained detailed guidance for staff on meeting the needs of the residents. The Inspector was able to observe the staff providing appropriate and adequate support. One prospective new resident was visiting the home on the day of inspection as part of the transition period. A staff member from the present placement accompanied the resident. This was commendable practice. Individual Needs and Choices (Standards 6-10) 4 of 4 standards assessed were met, 1 standard was not assessed. Care plans were in place covering all aspects of personal, social and healthcare needs. A review of the care plan information provided evidence that individual support programmes are developed for each person accommodated. The 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. The Inspector noted that information in the care plans reflects the persons choices and right to make decisions. During the inspection one resident confirmed her bedroom would soon be re-decorated and she had chosen the colour. As part of the inspection process the Woodhouse Page 6 inspector received comment cards from two residents. The comments were positive and conveyed that care provided was of a high level. Lifestyle (Standards 11-17) 6 of 7 standards assessed were met, 1 standard was not assessed. The inspector noted from evidence in the care plans that each resident had an individual plan, which included attendance at various day centres providing social and educational activities. One resident spoken with likes to go shopping and the Inspector was able to speak with visiting friends who confirmed the residents choices are always considered. One resident confirmed attendance at a day centre in another city close to where her parents lived which enabled contact on a regular basis. Visitors spoken with confirmed attendance at a review meeting for their friend who was presently accommodated in the home. The Inspector examined the kitchen area and found it to be clean and well organised. The Inspector noted gaps in the recording process when the cook was on annual leave. A requirement has been included to review the recording process to ensure all record re kept up to date when the cook is not present in the building. Personal and Healthcare Support (Standards 18-21) 4 of 4 standards assessed were met. The Inspector observed staff members interacting sensitively with the residents, and noted residents were given personal space where appropriate. Staff members spoken with were able to demonstrate a detailed understanding of the needs and preferences of the residents they were supporting. The Inspector found evidence in the care files of residents access to all relevant health care services. The Inspector reviewed the administration and storage of medication in the home. The training co-ordinator confirmed all team leaders have attended medication training delivered by the pharmacist. The district nurse has provided training on the administration of invasive medication. Only senior staff members administer medication. The storage and administration was up to date and in order. The Inspector recommended a date be inserted in the homely remedies record sheet. A requirement from the previous inspection to include in care plans the residents wishes in the event of death has been complied with. Concerns, Complaints and Protection (Standards 22-23) 2 of 2 standards assessed were met. The complaints procedure was displayed in the home and contained the contact details for the Commission for Social Care Inspection. Policies and procedures are in place to safeguard residents from any form of abuse. No complaints had been received since the last inspection. Environment (Standards 24-30) Woodhouse Page 7 4 of 7 standards assessed were met, 3 standards were not met. The home was bright, airy, and free from offensive odours. The furniture provided was domestic in character and of good quality. All areas of the home are accessible to persons using a wheelchair. The Inspector noted that the communal garden area was the subject of a requirement from the previous inspection. A trip hazard has been removed and the area made safe for use by residents and staff. The Inspector noted two sofas in the home, (one in a residents room and one in the communal lounge) were without soft cushions. These were being laundered. Alternative cushions should be provided during the interim period appropriate to meet the needs of the residents. A requirement will form part of this report to reflect this. The Inspector noted that no storage space was available to the maintenance person for the safe storage of tools and sundries required as part of his role in the home. The regulations require appropriate storage facilities be provided for the purposes of the home. The inspector examined the fire safety records, environmental safety records, and records related to food hygiene and temperature control in the main kitchen area. The Inspector noted when the cook and maintenance person were not on duty the records required by legislation in relation to these two areas of work in the home had not been completed. A requirement has been included in this report. Staffing (Standards 31-36) 6 of 6 standards assessed were met. The staff members spoken with demonstrated a good understanding of their role within the home. The home operates a key worker group system and the staff members demonstrated to the inspector a detailed knowledge of the resident they were allocated to as part of the key worker group. This is consistent with good practice. The Inspector was able to meet with the delegated training co-ordinator who explained a training programme has been developed to ensure 50 of care staff achieves NVQ level 2 by 2005. The Inspector spoke with staff members who conveyed enthusiasm and commitment to completing training tasks. The main concern of the staff spoken with was that no time is allocated to enable the staff members to collate information and complete training exercises. Staffing levels should be reviewed to ensure adequate time is allocated during duty shifts for report writing, supporting staff, monitoring of practice and to allow staff time to read policies and procedures and complete training materials. The Inspector reviewed the staffing information held in the home. There was evidence of a robust recruitment procedure in place.Conduct and Management of the Home (Standards 37-43) 4 of 5 standards assessed were met, 1 standard was not met, and 2 standards not assessed. Mr Robert Theobald has recently successfully completed the registered manager process. Woodhouse Page 8 The manager has qualifications equivalent to the Level 4 NVQ in Management Award. The manager demonstrated throughout the inspection process, his competence and experience to meet the stated purpose of the home. The Inspector noted the atmosphere was relaxed and friendly. Those residents able to communicate their wishes and feelings verbally did so with confidence. The staff members encouraged and provided choice for the residents in making decisions. The Inspector received three replies from residents in the form of comment cards issued prior to the inspection process. The comments received were all favourable. The care file information was up to date, detailed and in good order. The organisation has contracts in place to ensure external contractors carry out appropriate checks to equipment and the premises at regular intervals. Documentation and a formal recording system is in place.WoodhousePage 9 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY 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 actionAction 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 StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)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 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 13.4 (c) 16.2(c) 23.2 (c) 18.1(c)(j) YA17 To ensure all records continue to be kept up to date when staff are on annual leave or periods of sickness. To provide cushions on the sofa in the residents room and in the communal lounge. To provide COSHH training and risk assessments as appropriate for the domestic staff. Appropriate storage facilities be provided for the purposes of the home. To review the staffing structure and ensure support is available for staff providing individual care for long periods. To ensure all staff have relevant information enabling the development of positive relationships with persons accommodated. 30th September 2004 30th September 2004 30th October 2004 30th September 2004 30th October 2004 30th October 20042YA263YA30423.2 (L)YA24518.1(a)YA33612.5 (b)YA30RECOMMENDATIONS 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. Woodhouse Page 11 No.Refer to Standard * YA20Good Practice Recommendations1To include in the homely remedies record a date for each entry. Staffing levels should be reviewed to ensure adequate time is allocated during duty shifts for report writing, supporting staff, monitoring of practice and to allow staff time to read policies and procedures and complete training materials.2YA333YA35To include in the statutory training programme modules of anti-racism and equal opportunity training.* 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 YES YES YES YES NO NO YES NO YES YES YES YES YES YES NO NO 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)6 2 X YES YES YES YES X X 17/8/04 9.30 16The 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 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 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 If yes, please state what the extras are Hairdressing, Toiletries, Aromatherapy. 3 Key findings/Evidence Standard met? A statement of purpose and service user guide has been developed and contains all components required in his standard. The service user guide has recently been reviewed and contains pictures and symbols and a statement on the front page informs readers that the information is available in any language. The Inspector saw that each resident has a copy of the resident guide in their room. Some information had been omitted from the reviewed document and the manager agreed to ensure this would be inserted prior to final publication.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. 4 Key findings/Evidence Standard met? The Inspector reviewed the care files and found evidence of local authority assessments. The manager explained that a full assessment of need is undertaken prior to admission and individual plans are developed from this assessment. The development of the care plan includes information from relevant professionals, family members, the resident and persons significant to the resident. For example staff from previous placements that have worked closely with the person being accommodated. This was good practice. One prospective new resident was visiting the home on the day of inspection as part of the transition period. A staff member from the present placement accompanied the resident. This was commendable practice.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. 3 Key findings/Evidence Standard met? From evidence in the care files the Inspector noted that the residents needs were being met. The Inspector was able to observe the staff providing appropriate and adequate support. The care files contained detailed guidance for staff on meeting the needs of the residents. The residents told the Inspector they were happy in the home and support from staff was of a good standard. The Inspector noted the staff were able to communicate effectively with those residents who had limited communication skills. 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 Inspector found documentary evidence that staff were in the process of introducing a prospective resident to the home. Part of this transition period involved Woodhouse staff attending outings with the resident and staff members from the present placement. Trial visits to the home were being organised as part of the transition process and the Inspector was able to meet with the new resident during one of the trial visits. This was good practice.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. 3 Key findings/Evidence Standard met? Service contracts were seen on the residents files and contained all components of this standard.WoodhousePage 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. 3 Key findings/Evidence Standard met? The 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. A review of the care plan information provided evidence that individual support programmes are developed for each person accommodated. The Inspector found clear detailed guidance for staff in meeting the needs of the residents. Care plans were in place covering all aspects of personal, social and healthcare needs. The care file information had recently been prioritised and this made the information more accessible. The manager explained a review of the care plan format was presently taking place to ensure the plans focussed more on aspirations and changing needs. Evaluation and development would be the key principles of the revised format. This is in line with good practice.WoodhousePage 17 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. 4 Key findings/Evidence Standard met? The home accommodates people with complex communication and behavioural needs. The Inspector noted that information in the care plans reflects the persons choices and right to make decisions. During the inspection one resident confirmed her bedroom would soon be re-decorated and she had chosen the colour. The resident also confirmed attendance at a day centre in another city to maintain continuity of care prior to admission, and encourage contact with her parents who lived close to the day care facility. This is consistent with good practice. The Inspector observed the residents making choices in relation to food and beverages being prepared. The residents confirmed to the inspector they chose where to have their lunch. The cook explained some residents used their own kitchen facilities to prepare light meals and snacks. The Inspector observed one resident having lunch with their visitors. Lunch was prepared by the cook specifically for this visit. This is consistent with good practice.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? As part of the inspection process the inspector received comment cards from two residents. The comments were positive and conveyed that care provided was of a high level. The residents have various levels of communication and understanding therefore involvement in the development of policies and procedures is achieved mainly through the key worker group. The views of family members, friends and/or advocates are sought through the review process formally, and informally during visits to the home.WoodhousePage 18 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? 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. 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 fully assessed during this inspection. A confidentiality policy is in place at the home.WoodhousePage 19 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? The home has eight flats all with full kitchen facilities, and residents are supported and encouraged to prepare meals. An allowance is made available for the residents to purchase food and develop skills in budgeting. Staff spoken with confirmed two residents prepare their own meals. A social skills kitchen is available for use with individuals or a group.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. 3 Key findings/Evidence Standard met? The inspector noted from evidence in the care plans that each resident had an individual plan, which included attendance at various day centres providing social and educational activities. Residents spoken with confirmed that activities took place, and the Inspector observed residents going on an outing. The manager explained the prospective new resident was included in activities at the home as part of the transition period. This is consistent with good practice.WoodhousePage 20 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. 3 Key findings/Evidence Standard met? This standard is met. See standard 12. The residents are supported on a one to one basis and individual plans are developed to include the residents choices in relation to activities organised in the community. One resident spoken with likes to go shopping and the Inspector was able to speak with visiting friends who confirmed the residents choices are always considered.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 4 Key findings/Evidence Standard met? As discussed earlier in the report residents are enabled to choose from a range of activities both in the home and in the wider community. The accommodation provided lends its self to the promotion of independence and residents are encouraged to develop interests in the wider community. All activities are recorded in the care file information. 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). 4 Key findings/Evidence Standard met? The Inspector noted the maintenance of family links and contact with friends is an important part of the individual planning process. The Inspector observed visitors moving confidently around the home, and having lunch in the communal dining area. The cook explained for one resident who normally prepares her own food, lunch was prepared in the main kitchen(at the residents request) to enable her to entertain her guests. This is good practice. On resident confirmed attendance at a day centre in another city close to where her parents lived which enabled contact on a regular basis. Visitors spoken with confirmed attendance at a review meeting for their friend who was presently accommodated in the home. The visitors confirmed a high level of communication with the staff team, and conveyed to the Inspector a sense of involvement in the care of the resident. This is commendable practice.WoodhousePage 21 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). 3 Key findings/Evidence Standard met? The Inspector observed the residents moving confidently around the home. One resident was able to go to the office and collect her money for a trip out. The Inspector noted the relationship between the resident and the administrator was friendly and comfortable. The manager explained the use of locks on doors to the communal areas was restricted to ensure the safety of the residents. Any restrictions were within a risk assessment framework only. The Inspector noted the communal doorways were open on the day of Inspection. One resident was observed locking the door to her flat, and the staff member confirmed the resident had only recently begun using the key. Continual support and encouragement were offered to the resident as part of the individual plan to encourage independence. 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. 2 Key findings/Evidence Standard met? The Inspector examined the kitchen area and found it to be clean and well organised. All foodstuffs were appropriately stored and the records required for inspection were up to date when completed by the cook. The Inspector examined the following records: o Fridge and Freezer temperatures. o Dishwasher and food temperatures. o Food delivery monitoring, and stock control records. o Environmental risk assessments. o Cleaning rotas. The Inspector noted gaps in the recording process when the cook was on annual leave. The recording processes in relation to the preparation and storage of foodstuffs is a necessity to ensure the health and welfare of the persons accommodated. A requirement will form part of this report to reflect this. The Inspector is aware the home has faced many changes in the management structure and this has impacted on consistency of practice in some areas. The manager agreed to review the present systems to ensure continuity of the recording process in the absence of the cook.WoodhousePage 22 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. 4 Key findings/Evidence Standard met? Nursing care is not provided at Woodhouse. The Inspector found evidence in the care files of flexible and sensitive personal support as part of the individual care plans. 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. 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. Staff members spoken with were able to demonstrate a detailed understanding of the needs and preferences of the residents they were supporting. 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) X03 Key findings/Evidence Standard met? The Inspector found evidence in the care files of residents access to all relevant health care services. The manager explained that residents are supported to attend all appointments in relation to health.WoodhousePage 23 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. 3 Key findings/Evidence Standard met? The Inspector reviewed the administration and storage of medication in the home. Medication is stored in a designated cupboard, and a metal cabinet is used. A separate controlled drugs cupboard and register was in place. An audit of the controlled drugs revealed no errors and two signatures were present. The Inspector saw that a homely remedies record was also in use at the home. The homely remedies record did not include a date when the remedy was administered. The Inspector recommended a review of the format to include a date, name of resident, staff signature and a balance. An audit revealed no errors. The Inspector found evidence that a monthly audit is carried out on a regular basis and signed for by the staff member completing it. This is consistent with good practice. The training co-ordinator confirmed all team leaders have attended medication training delivered by the pharmacist. The district nurse has provided training on the administration of invasive medication. Only senior staff members administer medication. The medication storage area was clean and well organised.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. 3 Key findings/Evidence Standard met? The organisation has a policy in place giving guidance to staff in the event of a death in the home. A requirement from the previous inspection to include in care plans the residents wishes in the event of death has been complied with. The inspector noted the home had encouraged support from family members when compiling this information. This is consistent with good practice.WoodhousePage 24 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 X X X X X X X 3 Key findings/Evidence Standard met? The complaints procedure was displayed in the home and contained the contact details for the Commission for Social Care Inspection. This information was also contained in the service user guide. No complaints had been received since the last inspection.WoodhousePage 25 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 Inspector provided information to the manager on the implementation of the POVA list and amendments to the legislation, which will impact on the recruitment procedure in the home. A summary of the information was provided, and the Inspector advised the manager to obtain the Department of Health guidelines in relation to all changes.WoodhousePage 26 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. 2 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. All areas of the home are accessible to persons using a wheelchair. The Inspector noted that the communal garden area was the subject of a requirement from the previous inspection. A trip hazard has been removed and the area made safe for use by residents and staff. The Inspector was able to meet with the maintenance person who explained a programme was in place for the maintenance and renewal of the fabric and decoration of the premises. The Inspector noted that no storage space was available to the maintenance person for the safe storage of tools and sundries required as part of his role in the home. Day to day repairs and replacement of minor items such as light bulbs, which may require immediate attention, were an important part of this role. The regulations require appropriate storage facilities be provided for the purposes of the home. The Inspector was able to view the records completed for Water temperature checks in residents rooms (taps, showers and baths) External contractor certificates including laboratory sampling of water External contractor inspection of hoists and assisted bathing facilities. All records required by legislation were up to date when completed by the maintenance person. The Inspector noted that no records were kept up to date in the absence of the maintenance person. A system should be in place to ensure appropriate records are kept providing a safe environment for all persons accommodated.WoodhousePage 27 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 Key findings/Evidence YES NO NO 16 16 X X Standard met? 3 16 X16 X X XWoodhousePage 28 The Inspector noted that individual accommodation exceeded the space requirements of the legislation. Eight apartments with en-suite bathroom or shower facilities, depending on individual need and the option of the provision of kitchen facilities depending on individual choice, and provided through a risk assessment framework. The apartments have the electrical and plumbing facilities to be adapted quickly to meet the needs and choices of persons accommodated. This was good practice. The eight flats to the other side of the building consisted of a lounge, bedroom, bathroom with toilet and wash hand facilities, and a fully fitted kitchen. The Inspector viewed two of the flats and noted the residents had personalised the flats with personal possessions. The accommodation on the ground floor all had individual patio gardens. Individual accommodation was of a very high standard.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. 2 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, homely and comfortable. The Inspector noted two sofas in the home, (one in a resident room and one in the communal lounge) were without soft cushions. A staff member explained the cushions had been soiled and were being laundered. Alternative cushions should be provided during the interim period appropriate to meet the needs of the residents. A requirement will form part of this report to reflect this. 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. The manager explained the facilities provided would be changed according to individual need. There is an option to provide kitchen facilities in all rooms. A communal bathroom is available with assisted bathing facilities. Communal toilets are located near to the dining area.WoodhousePage 29 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. 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.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. 3 Key findings/Evidence Standard met? The home has been designed and built with reference to meeting the needs of the persons to be accommodated. All areas are accessible to wheelchair users. Grab rails, a passenger lift, and assisted bathing equipment have been provided. A social skills kitchen, hot tub room and two therapy rooms have been included at the home. The manager explained that adaptations to the rooms would be put in place according to individual need.WoodhousePage 30 Standard 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. 2 Key findings/Evidence Standard met? The Inspector noted the home was bright, airy and clean. There were no offensive odours in the home. The Inspector observed the domestic staff working diligently to maintain a high level of cleanliness in the home. The Inspector saw that a cupboard was in place for the storage of cleaning materials. There was little evidence in the storage area of guidance in relation to the Control of Substances Hazardous to Health. (COSHH) A COSHH file was located in the office however the domestic staff members were unable to demonstrate a detailed knowledge of the contents of the file. The Inspector could find no evidence of COSHH training being provided for the domestic staff, and discussion with the training co-ordinator confirmed this. A requirement will form part of this report to implement training for these staff embers. The staff members confirmed supervision from the deputy manager, and attendance recently on a Positive response-training programme. This is consistent with good practice. However the staff commented they are given no information when new resident are admitted to the home although they may come into contact with residents whilst carrying out their duties. The Inspector was impressed with the level of understanding of the residents needs and possible triggers to difficult behaviour conveyed during this discussion. Consideration should be given to providing a summary handover to all staff when a new resident is admitted to ensure consistency of practice, and minimise any distraction to enable them to settle in the home. Particular regard should be paid to any communication strategies in place for any new resident and behaviour difficulties or major changes relating to any resident in the home. The regulations require that staff are encouraged to develop and maintain good relationships with persons accommodated, and the domestic staff are an important element of the staff team.WoodhousePage 31 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 reviewed the staffing information and saw that job descriptions were in place. The staff members spoken with demonstrated a good understanding of their role within the home. The home operates a key worker group system and the staff members demonstrated to the inspector a detailed knowledge of the resident they were allocated to as part of the key worker group. This is consistent with good practice. The Inspector noted particular attention being paid to individual need in relation to the gender preferences and needs of residents.WoodhousePage 32 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 Inspector was able to meet with the delegated training co-ordinator who explained a training programme has been developed to ensure 50 of care staff achieves NVQ level 2 by 2005. 22 staff progressing through LDAF induction Funding being sought for a further eight staff 2 staff registered for NVQ level 2 (under 25 years old) funding available 12 staff to register for NVQ level 2 by end of 2004 (on completion of LDAF induction) 2 NVQ assessors already on staff team (1team leader and the deputy) 2 more team leaders to register for assessor award this year The training co-ordinator explained specific training is also organised to focus on particular conditions individual to residents. The Inspector spoke with staff members who conveyed enthusiasm and commitment to completing training tasks. The main concern of the staff spoken with was that no time is allocated to enable the staff members to collate information and complete the induction training. The staff members when on duty are supporting a resident on a one to one basis for the duration of the shift. This is further discussed in standard 33 and a requirement is made to review the staffing levels in consideration of support and training time for staff.WoodhousePage 33 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 9 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 XXX3 Key findings/Evidence Standard met? The statement of purpose and individual contracts determine the staffing levels in the home. Personal care and accommodation is provided for residents with complex needs and funding is sought which reflects the individual care the residents receive. The Inspector noted that each resident receives one to one care, and two to one care is provided where necessary. The roster provided evidence that shift team leaders are also allocated to a resident during their duty shift. A cook is employed to prepare dinner, however the staff are required to prepare the teatime meal. The roster showed there was little scope for the team leader to monitor or guide staff supporting residents on a one to one basis. Those staff preparing the tea or undertaking domestic chores did so at the expense of residents agreed support levels. One staff member confirmed at times she was supporting two residents. Staffing levels should be reviewed to ensure adequate time is allocated during duty shifts for report writing, supporting staff, monitoring of practice and to allow staff time to read policies and procedures and complete training materials. The building is split into two parts and the Inspector was concerned that the duty team leader would be required to support staff throughout the building. There was no communication system. The staff spoken with explained the call alarm was used if support was required. The team leader or other staff members would have to leave a resident unattended to offer support if necessary. The use of the call alarm would indicate a problem had arose rather than informal support being required. Consideration should be given to the provision of a communication system for use on an informal basis. Woodhouse Page 34 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 the staffing information held in the home. There was evidence of a robust recruitment procedure in place. The Inspector discussed amendments to legislation, which will impact, on recruitment procedures. The Protection of Vulnerable Adults Scheme was introduced on the 26/7/04 and involved a POVA list, which is required to be checked as part of the CRB process prior to the start of employment. The Inspector provided the manager with a summary of the changes and advised on where to locate a fuller explanation of the amendments.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 organisation have a training and development officer who co-ordinates the development of training initiatives for the organisation as a whole. The Inspector was able to meet with the staff member appointed as training co-ordinator for the staff team at woodhouse. The training co-ordinator explained that 22 staff members were presently progressing through an induction package accredited to the Learning Disability Award Framework. A training matrix was displayed on the office wall as a quick easy reference of training details for all staff. All statutory training was noted on the matrix, the Inspector noted that equal opportunity, or anti-racism training was not included as part of the training programme. The Inspector recommended a review of the training programme to include these areas of practice. The training co-ordinator explained mandatory training with the exception of Manual Handling was carried out in the home with the use of videos and questionnaires. The Inspector was unclear if the training co-ordinator was an accredited trainer, as COSHH, Food Hygiene and Health and Safety modules should be carried out by accredited trainers. The use of video training and questionnaires should be used to up-date formal training. The Inspector is aware the organisation has in place a four-day external induction package, which includes all elements of mandatory training. The Deputy Manager has achieved a certificate in manual handling training and offers this to staff members monthly or as required.WoodhousePage 35 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? A formal supervision programme was in place. The manager explained the team leaders provided supervision for their allocated key work group. The key work group consisted of four staff members. The deputy and manager provided supervision for the team leaders. The Inspector reviewed a sample of supervision records and found inconsistency in the frequency of formal sessions. The manager explained he was aware of the need to improve the consistency of the sessions throughout the staff team, and a formal monitoring tool has been developed to highlight areas of concern.WoodhousePage 36 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]. YES3 Key findings/Evidence Standard met? Mr Robert Theobald has recently successfully completed the registered manager process. The manager has qualifications equivalent to the Level 4 NVQ in Management Award. Mr Theobald has maintained his PIN number in respect of his RNMH registration, which expires in July 2005. The manager demonstrated throughout the inspection process, his competence and experience to meet the stated purpose of the home. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The Inspector noted the atmosphere was relaxed and friendly. Those residents able to communicate their wishes and feelings verbally did so with confidence. The staff members encouraged and provided choice for the residents in making decisions. The inspector observed a resident in the office collecting money to go shopping. The administrator had developed a positive relationship with the residents and this was apparent on the day of inspection.WoodhousePage 37 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 fully assessed during this inspection. The Inspector received three replies from residents in the form of comment cards issued prior to the inspection process. The comments received were all favourable.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 to reflect the national Minimum Standards. The Inspector noted introduction to the policies and procedures forms part of the induction process.WoodhousePage 38 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. 3 Key findings/Evidence Standard met ? The Inspector reviewed the care plans and associated information. The care file information was held in the residents rooms and accessible to the resident. The staff spoken with confirmed residents are actively encouraged to help maintain their personal records. This is in line with good practice. The care file information was up to date, detailed and in good order. The Inspector also reviewed the personnel information, and found evidence of a robust recruitment process in place. A training and development plan was in place and a formal supervision system had been implemented. The manager had developed a monitoring process to ensure supervision was carried out on a regular basis achieving compliance with the National Minimum Standards. The inspector examined the fire safety records, environmental safety records, and records related to food hygiene and temperature control in the main kitchen area. As discussed in standards 24 and 17 whilst the cook and maintenance person were not on duty the records required by legislation in relation to these two areas of work in the home had not been completed. A requirement has been included in this report. I should be noted these two staff members whilst on duty, have kept good detailed records as required and commensurate with the responsibilities of their respective posts.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. 3 Key findings/Evidence Standard met? This standard has been met. Discussion in relation to the health and safety of residents and staff and any improvements required are noted in the following standards: 24, 17, 35, 32, 30. The organisation have contracts in place to ensure external contractors carry out appropriate checks to equipment and the premises at regular intervals. Documentation and a formal recording system is in place.WoodhousePage 39 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 during this inspection.WoodhousePage 40 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance May accommodate up to 16 persons aged 18 years to 65 years. CommentsYESYES Condition Compliance May accommodate 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 CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateHelen Taylor Lyn Davis 28th September 2004Signature Signature SignatureWoodhousePage 41 Public reports It should be noted that all CSCI inspection reports are public documents.WoodhousePage 42 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 No commentsAction taken by the CSCI in response to provider comments:WoodhousePage 43 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 accurateNONONONote: 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 is to 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 44 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.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 OrWoodhousePage 45 Woodhouse / 17th and 19th August 2004Commission 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.V172103.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!