Inspection on 18/10/06 for Woodhouse

This inspection was carried out on 18th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodhouse 09/06/09

Woodhouse 17/07/08

Woodhouse 20/09/07

Woodhouse 24/03/06

Woodhouse 27/09/05

Woodhouse 01/03/05

Woodhouse 17/08/04

Woodhouse 12/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Woodhouse Wigton Crescent Southmead Bristol BS10 6DS Lead Inspector David Smith Key Unannounced Inspection 18th October 2006 10:00 Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodhouse Address Wigton Crescent Southmead Bristol BS10 6DS 0117 9581160 TBA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Shaw Healthcare (Specialist Services ) Ltd To Be Appointed Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 16 persons aged 18 years to 65 years. May accommodate one named person with a learning disability aged over 65 years. Registration will revert to 18 to 65 years when named person leaves. 24th March 2006 Date of last inspection Brief Description of the Service: Woodhouse 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. Woodhouse is a purpose built facility, first registered in July 2003 and is 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 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. Individual accommodation located on the ground floor all have small patio gardens. The basic fee for this service is £2400.00 per week. The exact fee level is dependant on the support needs of each individual service user. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit as part of a Key Inspection of this service. The inspector gathered information during this visit through discussions with service users, the Manager, Team Leaders and Support Workers. Interaction and communication between staff and service users was also observed during the course on the inspector’s visit. Care plans and associated records were examined together with Risk Assessments, accident/incident reports, complaints log, financial and health and safety records. The inspector was also provided with a tour of the home. Other sources of evidence have been used as part of the Key Inspection process. These include the home’s action plan in response to the last CSCI inspection and notifications of significant events which have been provided. The Commission also provided the home with a Pre-inspection questionnaire, Service User Survey Forms and a range of Comment Cards for stakeholders prior to this visit. The Pre-inspection questionnaire was completed and returned, together with six Service User Surveys and ten Comment Cards. What the service does well: Service users spoken with, and those who responded by survey, said that they are treated well by staff and they could do what they wanted to each day. Five families, who responded by comment card, said they were satisfied with the overall care their relative received. Specialised care and support is provided on a one to one basis and each service user is allocated a team of staff who provide consistent care. A person centred approach is promoted and communicated throughout the service. This ensures each individual is supported in this way. A wide range of professional expertise is actively used in order to support and maintain each service user’s lifestyle, health and well being. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Communication with relatives and health care professionals should be improved. This will help to ensure an open, inclusive and accountable service for each service user is promoted. The risk assessment process relating to the use of Positive Response Techniques must be improved. This would help to ensure the welfare and safety of service users and staff. The home’s complains procedure must be explained to each service user and their relatives. This will ensure each person is aware of how to raised any concerns they may have regarding the home. The planned maintenance currently in progress must be completed. This will improve the environment further for each person who lives in the home. All staff must be supervised on a regular basis. This will ensure all staff are supported to provide support to the service users. All staff must be provided with core and specialist training, including appropriate refreshers. This will ensure they have the knowledge and skills to support each service user. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 7 The organisation must ensure an application for registration is submitted by the Manager as soon as possible to help ensure an accountable service for each person who lives in the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with information they need to make an informed choice of where to live. There is an effective assessment process in operation. Each service user has the opportunity to visit the home, prior to moving in permanently. Each service user now has a personal contract detailing the terms and conditions of occupancy. EVIDENCE: The home has a comprehensive Statement of Purpose, which describes all aspects of the service. This document has been recently updated. There is a detailed admission process in the home that focuses on the support needs of each individual. Placements at the home are normally funded through the Health Authority in conjunction with the Social Services department. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 10 Detailed assessments from various professionals involved with the individuals are provided with the initial application. There has been one admission to the home since the last inspection. This service user’s care records were examined and these showed that comprehensive assessments were carried out to ensure the home could meet their support needs and introductory visits were made to the home prior to them moving in permanently. Service users spoken with said they chose to live in this home. Five service users who responded by survey said they were provided with enough information regarding the home, to enable them to choose if they wanted to live at Woodhouse. One service user said they did not. Four said they were asked if they wanted to move to this home, while two said they were not asked. Each service user now has a contract, which details the terms and conditions of occupancy and includes the fee they are expected to pay for their service. These documents now only need to be signed by the Area Manager to complete this process. This is a positive development. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users now benefit from a more detailed care plan, which is regularly reviewed. This process needs to be completed for each service user. Each service user is supported to make their own decisions and choices in everyday life. Service users views are sought and acted upon in relation to the home. The Risk Assessments process support service users to take risks as part of their lifestyle. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 12 EVIDENCE: The care planning and review processes within the home are good. The Shaw Trust have recently issued new care planning templates, which are being implemented by the home. This new system contains four areas of each service user’s care and support needs. These are ‘Essential Lifestyle Plan’, ‘Support Guidelines’, ‘Healthcare’ and ‘Behaviour’ but only if this last section is relevant to the person. Staff are currently working hard to transfer all care plan information into the new format. One service user, whose plan has been adapted, spent time with the inspector and discussed their care plan in detail. They told the inspector they had decided what was contained in their plan and they had been helped by their keyworker. It was evident that the new system of care planning is much more effective and is in line with the person centred approaches promoted by the home. The care plans which remain in the old style are much more difficult to navigate and do not appear to be particularly user friendly. All of the staff spoken with feel the new care planning system is a positive development and hope to transfer all plans to the new system shortly. Each care plan is reviewed regularly. The care of each service user is reviewed with the relevant Funding Authority, who provide a summary of each review meeting, together with the outcomes. Each care plan is then updated. The home provides a service for people who have a variety of complex needs, however all service users are encouraged and supported to make informed choices. Care plans clearly describe how to support each person with this process and what boundaries or limitations may be needed for some individuals. Service users spoken with said they were able to make decisions and that staff supported them to do this. Those who responded by survey had mixed views. When asked do they make decision about what to do each each day, two said ‘always’, one ‘usually’, one ‘sometimes’ and one ‘never’. The home seeks the views of service users, either through day-to-day contact/ discussion with them, more formal meetings or surveys. The home works hard to ensure that their views are acted upon wherever possible. The inspector noted that one Support Worker who had been praised by a number of service users for improving the menu within home has recently been appointed as chef. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 13 The Manager told the inspector that they are looking at ways of improving service user involvement within the development of the service. New service user survey forms, using more pictures/picture symbols are being piloted as well as discussions within the organisation regarding establishing a new Service User Steering Group. Each service user has a number of person centred Risk Assessments, which support them to take risks as part of their lifestyle. These form part of each person’s care plan, are clearly written and are subject to regular review. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported to take part in appropriate leisure activities and training sessions. Service users are supported by staff to use community facilities, enjoy holidays and visit families and friends. Person centred planning is prominent in the service. This enables service users to participate in a wide range of activities and supports each person to develop their own service. A varied and healthy menu is now being developed within the home. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 15 EVIDENCE: The home has a person centred approach in supporting each service user to develop. The records maintained within the home enable each persons progress to be assessed and the support provided adapted accordingly. Service users have their own weekly timetable of activities. During the inspector’s visit service users were supported to access community facilities, such as day centres as well as other venues. One service user told the inspector they enjoyed their computer college course and would now be able to use the computer in the home’s office. The records examined show that service users enjoy a variety of activities such as shopping, going to the library, Gateway Club, local pubs, theatre trips and days out to coastal resorts. Each service user is supported to choose, organise and attend a holiday. One service user spoken with said they had recently been on holiday to Spain, which they really enjoyed. Service users are supported to maintain regular contact with their family and friends and visitors to the home are welcomed. A relative was visiting one service user on the day of the inspector’s visit. Seven relatives responded by comment card. Each said they could visit their relative in private and six said they were welcomed to the home at any time. One said they did not feel they were made welcome to visit. Six said they were consulted about their relative’s care, one said ‘not fully’. Four said they were kept informed of important matters regarding their relative, whilst three said they were not. Observation during the inspector’s visit and discussion with staff evidenced that each person who lives in the home is treated with respect and dignity. Each person is seen as an individual and treated as such. It was noted at the last inspection that the menu was somewhat unimaginative and there was no emphasis on fresh produce. The opportunity was therefore taken to meet the chef and discuss the changes regarding menu plans. The manager and the chef told the inspector of the positive changes that have now taken place. The menus have been improved and these are focused on promoting a healthy and balanced diet for each service user. Individuals with special dietary requirements or who require additional support around food/nutrition are now focused upon more closely. A pictorial menu book has been started and this will help service users to become more involved in menu planning. The meal of the day will be displayed pictorially to ensure service users know what they can expect. This is good practice. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 16 Other service users spoken with said they preferred to make their own meals in their apartments and confirmed that they could choose the menu and staff supported them to shop for the ingredients. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans clearly explain the support each service users requires in relation to their personal and health care. Experienced staff have a good knowledge of each service user and how to provide appropriate levels of support. A monitored dosage system of medication for service users is in operation and this is well managed. EVIDENCE: The care plans in place for service users provided clear guidance for staff on how they should support those living at the home with their personal/health care. The care plans examined showed that service users were registered with a local GP, dentist, optician and chiropodist. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 18 Other specialist services are accessed when an identified need arises. These are provided by Bristol North Community Learning Disability Team. Care records show the Consultant Psychiatrist, Psychologist, Community Learning Difficulty Nurse and Dietician regularly support the home. Contact with each professional is recorded and forms part of each persons care plan. Three health care professionals responded by comment card. Two said the home worked in partnership with them and they were satisfied with the overall care provided by the home. One said they do not feel the home worked in partnership with them and the care ‘fluctuates, could be improved’. They also stated they felt ‘communication is poor’ and ‘had often been frustrated (their) advice has not been acted upon’. Despite the recent staff changes, a core of experienced staff remains who have a good knowledge of service users health care needs. Staff would act on any concerns they have and the quality of the record keeping in this area would help identify areas of concern. The inspector observed staff interacting with service users within the home and it was evident that they are sensitive to the personal/healthcare and emotional needs of those using the service. The home uses the Boots Monitored Dosage System of medicine administration. This system is well managed. The medication administration files contains a photograph of service users, details of PRN medication protocols, manufacturers notes of all prescribed medication and regular medication checks are carried out. Each service users’ medication record was correctly completed, signed by staff with no gaps evident in the records. Medication in the home is dispensed by Team Leaders, who are either qualified nurses or have been provided with appropriate training. The inspector spoke with the Manager and one Team Leader regarding the use of epilepsy mediation, Buccal Midazolam. The ‘Joint Epilepsy Council’ has recently issued guidelines regarding the administration and storage of this medication. The home should therefore consider reviewing current practice to ensure it is in line with the JEC guidance. Each health care professional who responded by comment card said they felt medication was generally well managed Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy and procedure is robust, clear and effective and there is every indication that service users feel their views are listened to and acted on. However, the home must ensure that all stakeholders are aware of the complaints procedure. Clear reactive strategies are in place for each service user who presents challenging behaviour. Risk Assessments must be improved in relation to Positive Response Techniques. The staff team are provided with training and support to ensure the welfare and safety of service users. However, this must be provided consistently for each member of staff. EVIDENCE: The home has a comprehensive formal complaints policy and procedure in place to ensure that all stakeholders are listened to. There is a flow chart for staff to be able to monitor the procedure, with explicit timescales. The Commission’s contact details are also included. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 20 The complaints log was examined. There have been two concerns raised since the last inspection. These have been taken seriously and investigated in accordance with the home’s policy. The outcomes had been clearly recorded. The home has also recently addressed poor work practice with two members of staff. These issues were taken seriously, investigated and appropriate action taken by the home to ensure the welfare and safety of service users. Both staff members have been dismissed by the home, following the investigation process. All of the service users spoken with, and those who responded by survey, said they knew who to speak to if they were unhappy. However, three service users and three relatives surveyed said they do not know how to make a complaint or were not aware of the home’s complaints procedure. The home has clear guidelines in place for supporting service users who are distressed or presenting behaviours which may be perceived as challenging the service provided. Each care plan has details of known trigger points and the appropriate defusing techniques. The home still needs to improve Risk Assessments in relation to individuals who require staff intervention as part of their behavioural support plan. These are not detailed enough and do not clearly describe what type of intervention may be used with individual service users or at which point during an incident they may be used. The inspector suggested the home accesses the Department of Health’s guidance in relation to Restrictive Physical Interventions to support this process. Staff record each incident of challenging behaviour. The home also maintains records of all other accidents and incidents and notifies CSCI of any significant events which occur in the home. Staff receive training in responding to challenging behaviours using Positive Response Techniques (PRT). Staff are also provided with training in relation to the Protection of Vulnerable Adults and are subject to Criminal Record Bureau enhanced disclosures. The inspector noted however that staff training had become irregular. Some staff had not received all of the core training in this area or others required refresher training. The Manager confirmed that she is aware of this issue and has identified dates to enable staff to receive the appropriate training. Service users finances are well managed, with clear records being maintained. Three were examined in detail by the inspector. All of the cash balances, income into accounts, expenditure and associated records were thoroughly checked and found to be in order. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable environment. Some areas of the home have been improved, however the planned refurbishment of the home must be completed to ensure a safe and homely environment for each service user. Each person has decorated and furnished their apartment/flat to suit their individual tastes and needs. The home was clean and tidy during the inspectors visit. EVIDENCE: Woodhouse is a purpose built home, set in its own grounds. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 22 The inspector viewed all communal areas of the home, together with service users’ apartments or flats where appropriate. All communal areas were clean and tidy on the days of the inspectors visit. All of the service users’ apartments/flats, which were viewed, were clean and tidy and were personalised with individual belongings, pictures and photographs. Each service user spoken with said they liked their home and were happy with the environment. Five of those who responded by survey said the home is ‘always fresh and clean’ and one said ‘usually’. The life skills kitchen was in use and it was evident that service users were supported to make snacks and meals of their choice. The spa room also continues to be popular. The Manager told the inspector that the environment is currently being improved in a number of areas. The large lounge/dining area now has more furniture, looks more homely and is being used more by service users. Service users artwork is being displayed, with more planned and this helps to personalise the home. All of the communal corridors now have pictures fixed to the walls. Each of these developments has helped to enhance the environment and the homely feel. Contractors were seen working in the home during the inspector’s visit. New laminate flooring had been laid in the communal corridors and some communal areas were being repainted. Some of the flats/apartments, which are currently unoccupied, have been redecorated and re-carpeted. Their fixtures and fittings are of a high standard. The sensory room is currently being decorated and furnished. This is in place of the ‘keep fit’ room, which was hardly used. Each service user has been consulted on what they would like the sensory room to contain and how they would wish to use it. It is clear that once this area is completed, it will provide a valuable resource for each person who lives in the home. The inspector did recognise areas within the home which required attention. Examples being one of the communal lounges on the first floor requires repair/redecoration and kitchen units to be removed from one communal lounge on the ground floor, however, the Manager explained this work was scheduled and would be completed. The inspector accepts that this visit to the home occurred whilst the home is being refurbished and improved and is confident that when completed, the service users will be provided with a much-improved home environment. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 23 Improvements have been made to the garden area, with the addition of colourful sensory decorations appropriate to meet the diverse needs of the service users. The Manager told the inspector it was hoped this could be developed further, with the addition of a raised sensory garden area. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a core of experienced staff who have a good knowledge of their support needs. The staff team continue to become more cohesive and effective in supporting the service users. Vacancies within the staff team must be recruited to. All staff files contain all relevant information to ensure a robust recruitment process, which protects service users. The training programmes are designed to ensure that staff are provided with the guidance and skills to provide support to each service user. All staff must be provided with both core and specialist training, including appropriate refreshers. All staff must be supervised on a regular basis, to ensure they are supported to provide appropriate support to service users. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 25 EVIDENCE: There have been a number of recent changes within the staff team, which has led to staff leaving the home to pursue new opportunities. However, a core of experienced and committed staff remain who work hard to provide support for service users. The home has recruited new staff, although vacancies within the team remain. The Manager told the inspector that the recruitment process remains ongoing until all vacancies within the team are filled. Of the ten comment cards returned, seven respondents expressed concern regarding staffing levels within the home and the effect on the consistency of staff support for service users. The inspector spoke with several members of the staff team during this visit. Each staff member confirmed that they enjoyed working in the home and now felt well supported in their role. The staff team meets regularly. Staff spoken with said they feel they can speak openly and honestly at team meetings and that their views are valued. Each service user spoken with said that they liked the staff and they always tried to help them. Each of those who responded by survey said they were ‘always’ treated well by staff. There are various training opportunities available for staff. Training records show that staff are expected to complete statutory training, induction and other relevant training sessions such as Autism, Dementia and Epilepsy. It was noted however that not all staff had completed all statutory training and others were still to attend more specialist training courses. This was discussed with the Manager who explained she was aware of this issue and had ensured all staff are now booked on to all relevant courses, including refresher training. Staff complete LDAF Induction and Foundation, then progress to an NVQ qualification. Only one staff member has an NVQ at present. The home has already had discussions regarding supporting staff to gain these qualifications, including training one staff member to gain the A1/A2 NVQ Assessors Award as well as accessing external training providers. The progress in this area will be focused upon during the next inspection process. The home operates a robust recruitment process. The staff personnel files examined showed that these contained a photograph of the staff member, copies of application forms, proof of identity, satisfactory references and an Enhanced Criminal Records Bureau Disclosure. Each staff member must satisfactory complete a six month probation period, before being offered a permanent post. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 26 Staff are supervised by senior members of the team. However, the records show that supervision has become irregular for many members of the staff team. The Manager accepts this and has recently changed the supervision structure, which is improving this area. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has effective procedures in place to provide service users with the support they require. The organisation must ensure an application for registration is submitted by the Manager. The ethos of the service remains clear and this is communicated throughout the service. The views of service users are actively being sought in relation to the quality of the service. The health, safety and welfare of the service users is promoted and protected. Fire safety has now been improved within the home. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 28 EVIDENCE: The Registered Manager has now left the home, after a period of sick leave. The Deputy Manager, who has been acting Manager during this time, has been promoted and is now the Manager of Woodhouse. The inspector spoke with the new Manager at length and it was evident that they are clear on their role and have already identified several areas where either improvements can be made or new ideas implemented. They told the inspector they are well supported by their line Manager, who visits the home regularly. The organisation must ensure an application for registration is submitted by the Manager as soon as possible to enable the process to be completed. The management systems and structures have been reviewed by the Manager, assisted by the home’s administrator. These have been improved and are now more efficient. The record keeping is of a good standard. Files and documentation are now very well-organised and easy to access. The ethos of the service is person centred. Staff spoken with said their views are listened to, and that they are well supported by the manager. Service users spoken with said they are supported to air their views and felt that they were listened to and acted upon. Of the six who responded by survey, four said staff ‘always’ listen and act of what they say, one said ‘usually’ and one ‘sometimes’. Both the home and the organisation continue to develop ways to engage service users so that their views help to improve the service. These initiatives are mentioned previously in this report. There are recording systems in place to support Health and Safety within the home, which are being used consistently. Records examined included hazardous products used within the home, portable electrical appliance testing, monthly health and safety audit and the annual health and safety schedule. All of these records were in order and checks were up to date. During the last inspection the fire logbook was examined and it was noted that the fire alarm testing was not taking place within timescales prescribed by the Fire Brigade, call points were randomly tested which meant that one hadn’t been tested for a number of months and the fire logbook didn’t contain any staff training details. Fire safety has now been improved in each of these areas and records are now up to date. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 29 There are a number of generic Risk Assessments in place. These are comprehensive and subject to regular review. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X 3 3 X Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13(4)(c) 13(6)(7) Requirement The Risk Assessment process relating to the use of PRT must be improved. (This is a repeated requirement form the last inspection report). 2. YA35 18(1) All staff must be provided with training: 1) Which meets all Shaw Healthcare core standards. 2) Which provides all staff with additional relevant skills to support service users. 3. YA32 18(1) The home must devise a clear plan detailing how staff are to be supported to gain a National Vocational Qualification and supply this plan to the Commission. 18/01/07 Timescale for action 18/01/07 18/01/07 Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 32 4. YA22 22(5)(6) All stakeholders must be made aware of the home’s complaints procedure. Ensure the planned maintenance/improvements are completed to ensure a safe, comfortable and homely environment. All staff must be supervised on a regular basis. Ensure an application for registration is submitted by the Manager. 18/01/07 18/01/07 5. YA24 23(2) 6. 7. YA36 YA37 18(2) 9 18/10/06 18/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA20 Good Practice Recommendations All care plans should be transferred into the new care planning system as soon as possible. Consider reviewing the medication administration/storage relating to Buccal Medazalam in line with JEC guidance. Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodhouse DS0000044679.V315579.R01.S.doc Version 5.2 Page 34 - 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!