Inspection on 14/04/08 for Woodhouse Hall

This inspection was carried out on 14th April 2008.

CSCI found this care home to be providing an Adequate service.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodhouse Hall 15/10/07

Woodhouse Hall 22/05/07

Woodhouse Hall 28/11/06

Woodhouse Hall 16/03/06

Woodhouse Hall 01/12/05

Woodhouse Hall 27/01/05

Woodhouse Hall 20/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Whitwood House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Woodhouse Hall 14 Woodhouse Lane East Ardsley Wakefield West Yorkshire WF3 2JS Lead Inspector Stevie Allerton Key Unannounced Inspection 14th April 2008 08:45 Woodhouse Hall DS0000001523.V365202.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 Hall DS0000001523.V365202.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 Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodhouse Hall Address 14 Woodhouse Lane East Ardsley Wakefield West Yorkshire WF3 2JS 01924 870601 01924 820939 woodhouse.hall@craegmoor.co.uk www.craegmoor.co.uk J C Care Ltd 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) Care Home 13 Category(ies) of Learning disability (13), Physical disability (13) registration, with number of places Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th October 2007 Brief Description of the Service: Woodhouse Hall is owned by J C Care, which is a subsidiary of Craegmoor Health Care. The service is registered to provide care and accommodation for up to thirteen adults who have a learning disability. So as not to have people sharing a bedroom, the maximum number of people being cared for is eleven. At the time of the inspection only seven people were living at the home. Woodhouse Hall is a semi-detached property. It is joined to another care home, owned by the same company. The home is situated in its own grounds and ample parking is available to the front of the building. The home is on two levels. On the ground floor there are two bedrooms, a kitchen area, a lounge and separate dining room, a shower room, bathroom and two offices. On the first floor are the remaining bedrooms, bathrooms and a second lounge area. There is a main staircase; there is no passenger or stair lift. There is a concrete ramp to the front of the building. The home is on Wakefield Road in East Ardsley, between Leeds and Wakefield. It is within easy walking distance of the main road and is well served by public transport. There are a number of local amenities, which are well utilised by people who use the service. The fees charged by the home range between £500 and £1,431 per week. This information was provided in April 2008, during the inspection. Information about the home including a Statement of Purpose, Service User Guide and previous inspection reports are available at the home. Up to date information about fees can be obtained directly from the home. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out without prior notification and was conducted by one inspector over the course of two visits. The first, on 14th April, was from 8:45 am until 1:15 pm and the second visit, on 17th April, was from 12:30 pm until 5:30 pm. Before the visit, accumulated information about the home was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI since the last inspection. The home also completed an Annual Quality Assurance Assessment (AQAA). In the six months since the last key inspection took place, there have been two random unannounced inspections. One took place in November 2007, following which a Statutory Requirement Notice was issued in respect of breaches in the Care Homes Regulations that had been found. A follow-up inspection was carried out on 3rd January 2008, and it was noted that a lot of progress had been made and that most of the requirements had been met. CSCI agreed to extend the timescales for the outstanding requirements, to allow the current management team to continue with their action plan. All of this information was used to plan this inspection visit. Some staff surveys were left at the home, five of which were completed and returned. Their comments are included under the relevant outcome headings of the report. Two people were case tracked, and other files were looked at. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, all twenty-one key standards from the Care Homes for Younger Adults National Minimum Standards, plus other standards relevant to the visit, were able to be assessed. We spent time with people living at the service and spoke to relevant members of the staff team who provide support to them. The new manager, Hazel Pogson, and the acting Business Support Manager, Angela Galloway, were both involved with the site visits. They were joined by Melanie Ramsey, Area Manager, for feedback at the end of the inspection. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The company has taken on board the serious shortfalls that had been identified in the past, and put an effective action plan in place to resolve these. The home now has effective management and administration in place, so it runs more smoothly. A new manager has been recruited and had been in post for five weeks at the time of this inspection. The range of activities and social opportunities on offer is increasing, so that people have been able to get out and about more. Staff felt that activities had improved peoples lifestyles: “We give the service users an independent lifestyle, where they are guided in looking after their personal needs, and take great care in taking them out on activities to experience life in the community”. There are more opportunities for self-advocacy, through the “Your Voice” initiative, regular house meetings that actively encourage people to speak up for themselves. The home tries to have a flexible daytime routine and has made some changes so that people are provided with a more flexible lifestyle. Staff feel that they are providing a good level of care to people living at the home. One comment was: “Since additional support has been given to Woodhouse Hall, the lifestyle and care given is excellent to all service users”. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 7 Staff also said that they have found the new care plans very helpful and welcome the increased level of information, as it helps them to understand service users’ needs better. The programme of redecoration is underway, and efforts have been made to reduce odours in various locations in the home. Staff said, “The house is now very well-organised, nice and clean, its a pleasure to work there now, its very well-kept”; “ The decor and atmosphere in the home has improved”. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodhouse Hall DS0000001523.V365202.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 Hall DS0000001523.V365202.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 and 2. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. There is clear information about the home and what people can expect from it, which will help people to make a decision about whether to move in or not. Because admissions to the home have been halted, this has given the staff time to make sure that everyone who lives there is being properly assessed and helped to find a more suitable place to live if need be. The service understands that new admissions to the home should not be made until a full assessment of the persons needs has been carried out. This will make sure that the home only accepts people who they are sure they can look after properly. EVIDENCE: There are still no new admissions, the company deciding not to admit anyone until the standards at the home had improved consistently. Therefore it was not possible to assess whether the requirements that relate to the admission process have been met. The statement of purpose is currently being updated. A laminated service user guide is contained within the person centred planning file, this is an accessible document for people with learning disabilities, supported by pictorial images. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 10 It also outlines the complaints procedure and up-to-date contact details for the link inspector. Each person has been reassessed to ensure that the service where they live is appropriate to their needs. Some people have moved on to alternative care as a result of this. In one of the care plans looked at in depth there was a recent assessment for autism specific services. Woodhouse Hall DS0000001523.V365202.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 and 9. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Care planning has continued to improve; the person centered plans (PCPs) are easy to understand and look at all areas of the individuals life. This makes sure that no areas where support is needed are missed. Detailed written guidance for particular areas of risk or need make sure that staff know how individuals want to be supported. The use of person centered plans will give individuals more opportunity to influence how their own care is delivered. EVIDENCE: Two people were case tracked; their files were looked at in depth, and crossreferenced by conversation with them, where possible, and observations of the support people actually received. Both people are currently receiving one-toone support during the day and the files showed that the one-to-one support was assigned to named staff every day. Support plans are based on person centered care planning. One specific area of support identified for one person was social interaction. A problem or risk Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 12 was identified, assessed and a specific support plan put in place; for example, journeys in the home’s vehicle - staff to escort in the vehicle and sit next to the person. There is also a specific support plan in place regarding visitors to the home. The practice seen on the day of the visit was in line with the support plan, staff supporting the person in the way described in the plan, introducing us to the person and reassuring him about the purpose of our visit. The support plans are evaluated monthly. Support needs regarding religion and language are included in the assessment information and where a need is identified, support plans are put in place. Theres also a section in the support plans about consent to share information, signed by the individual, which is good practice. The “Every Day” plan describes the weeks structure and activities, which for one person showed a mixture of normal activities of daily living, including taking the post to the mailbox everyday, and trips out. This plan also shows how his finances are managed by the staff. Another person’s file showed that he had had a recent reassessment to see whether autism specific services would be more suitable. Staff currently give him one-to-one support. He was unable to express an opinion to us about his care but appeared to be engaging well with the staff supporting him. Staff surveys: staff feel they are given up-to-date information about the people they support by way of the care plans. People in the home are encouraged to make their own decisions by way of the regular house meetings (“Your Voice” meetings). The provider has stated in the AQAA that one area identified for improvement is to involve residents more in making decisions about their own lives, to increase their confidence, provide more information and support in order for them to achieve their goals. Action had been taken to resolve every issue within the Statutory Requirement Notice by the time of this inspection. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 13 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, 15, 16 and 17. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The range of activities and social opportunities on offer is increasing, so that people have been able to get out and about more. However, more recreational and leisure opportunities tailored to the individual would increase peoples chances of fulfilment. There are more opportunities for self-advocacy, through the “Your Voice” initiative, regular house meetings that actively encourage people to speak up for themselves. The home tries to have a flexible daytime routine and has made some changes so that people are provided with a more flexible lifestyle. People are provided with a healthy and varied diet, which promotes their health and well-being. EVIDENCE: Daily activities records show regular trips out in the minibus to parks in the area, walks, picnics and trips to garden centres. People also regularly help Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 14 with the supermarket shopping. In the house people enjoy music, TV, DVDs, jigsaws, craft activities and baking sessions. Some people access the organisation’s day-care centre off site, but there are currently limited opportunities for further education. During the week of the inspection the city council were doing some road safety training with people. One-to-one support plans showed written observations on the one-to-one care monitoring charts. They also outlined what activities the person had taken part in, their mood, the choices they had made, times of getting up and going to bed etc. There are monthly meetings for the people living at the house called the “Your Voice” initiative, the minutes of which were seen. Staff said that they felt that activities had improved peoples lifestyles, “ We give the service users an independent lifestyle, where they are guided in looking after their personal needs, and take great care in taking them out on activities to experience life in the community”. A comment was made that more activities should be provided outside the home in small groups, e.g., groups of two people with two staff. Menus are planned around residents’ choices and shopping is generally done at one of the large supermarkets in the area. One of the support workers takes a particular interest in cooking and was introducing a new menu format the following week. She engages some of the residents in baking or helping to make the evening meal, which was seen during the site visits. There is a food comments book where staff record what was liked and disliked; this has helped in the production of the new menus. Staff said they felt that the meals provided were of good quality, well balanced and the choice was good. There was also evidence in support plans that specialist support from a dietician had been accessed with some success, with one person gaining weight and there was evidence that can have extra snacks and drinks at any time. Some people have food and fluid intake charts, where there has been concern about this area of their care. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 15 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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People receive personal and health care support that is centered on upholding their rights, dignity, equality and respect. Recent assessments have included input from relevant healthcare professionals, which has led to improvements in the way that personal care is delivered. Structured support plans in place show a good understanding of individuals’ specific needs, particularly communication, and make sure the staff know how these needs are to be met. Medication is managed safely, which protects people and makes sure that their health is properly managed. EVIDENCE: Peoples’ records showed that good attention is being given to health care; there is a Health and Keeping Safe area within the Person Centred Plans, that helps to identify where specific support plans need to be put in place. One of the files looked at in depth showed that this was a new addition in place since November. A Health Action Plan was in place, along with a personal hygiene routine, written in the first person. Risk assessments were also in place for moving Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 16 and handling and falls. There was evidence of areas that this person could be independent in, for example, choices: he likes his bedroom door to be locked but prefers the staff to keep hold of the key and he asks them for it. On arrival at 8:45 a.m. on the first visit, two people were ready and waiting downstairs for transport to the day centre. Staff were supporting other people, getting their breakfast, etc. The morning routine seem to be going fairly smoothly and was not chaotic. Person Centred Plans also contained evidence of multidisciplinary input and records of visits by other healthcare professionals. It was noted in one support plan that one person requires three staff members to accompany him to medical appointments; this was confirmed through the daily records. This person has autism and there was a structured plan in place to get him to wear some new shoes; the way that the support plan had been developed showed a good understanding of his needs and the way he communicates. The daily notes being made by the staff recorded his response to this approach and showed some success with the plan. Another example of a structured support plan was seen in respect of activities of daily living, supporting someone to get up showered and dressed in the morning; there was a clear plan of action for staff with 30 minute prompts to the person, and the daily records reflected this. Staff surveys: staff feel that they are providing a good level of care to people living at the home. One comment was made, “ since additional support has been given to Woodhouse Hall, the lifestyle and care given is excellent to all service users”. Staff also said that they have found the new care plans very helpful and welcome the increased level of information as it helps them to understand service users’ needs better. The Person Centred Plans showed that medication reviews had been carried out a few weeks previously for all people; there is a tool for assessing whether someone is able to self-medicate and these were seen in the file (no one currently can do this). Nurses from the Community Learning Disability Team in were involved in the reviews, which also monitored the use of PRN medication (prescribed to be given at the staffs’ discretion). One persons daily notes revealed an incident that had occurred which required her to be given PRN medication. We had been informed of this via a regulation 37 notification, which the records verified. The storage and system for administering medication was looked at: there is a locked room on the ground floor specifically for this purpose, equipped with a fridge and a storage trolley. The home uses the Boots’ Monitored Dosage System. The medications file contains the recording charts and user information leaflets, along with clear guidelines for the use of PRN medication. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 17 There are efficient systems in place for obtaining repeat prescriptions and returning unused medication to the pharmacist. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 18 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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The complaints procedure is clearly written and easy to understand; this is also discussed regularly during the “Your Voice” meetings, so that people living in the home can understand how to make a complaint and what will happen if they do. The home makes sure that only staff who are properly vetted and checked are allowed to work there, which helps to protect vulnerable people. Staff also receive a good level of training in safeguarding and protecting vulnerable people. EVIDENCE: The staff spoken to said they had attended safeguarding training and the training records reflected this. The provider has been investigating a complaint from a relative and the response letter was seen. Incidents of fallouts between people have continued to reduce, as those with challenging needs that could not be met within the service have moved out. Minutes of the “Your Voice” meeting were seen; this provided evidence that staff discuss how people should complain, people saying things like “I would Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 19 tell the boss” and “talk to my key worker”. The service users’ questionnaire has been rewritten to incorporate pictorial symbols. Two people have been referred for independent advocacy. The AQAA states that complaints procedures are on display in different areas of the home, now in easy read format. These were seen during the visit. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 20 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 and 30. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People live in a safe, well maintained, clean and comfortable environment that meets the needs of those currently living there. People are encouraged to personalise their own bedrooms, which gives them a sense of ownership. Redecoration and some new furniture are contributing to the improvement in atmosphere in the home. There is good attention to hygiene and infection control, which protects people. EVIDENCE: Decorators were in the house during the week that the inspection visits took place, redecorating the hall. The managers said that there was quite a large redecoration programme planned, but they were staggering it so as not to overwhelm people with changes. Communal rooms had been done first, with some renewal of furniture and modernisation. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 21 People spoken to said they have been involved in going shopping for choosing new furniture and pictures. The vacant bedrooms are being redecorated and furnished as “show rooms”, in readiness for the vacancies to be filled. One person showed us his room by invitation; he said he was pleased with it and had enough room for his personal things. He liked to have his door locked, but preferred the staff to look after the key. There was a bad odour in one of the vacant bedrooms but this was being addressed. An extra ventilation fan had been fitted and deep cleaning had been carried out using an antibacterial agent (this had already improved by the second visit three days later). The new manager was seen to remind staff about infection control procedure, and the prevention of cross infection with the correct use of protective aprons. Disposable gloves and alcohol rubs are available, stored in the laundry room. The previous problem with ventilation in the ground floor bathroom has now been addressed. Kitchen hygiene appeared to be good, the kitchen is clean and well organised and food appropriately labelled. The managers have been looking at the fire evacuation plan and liaising with the fire officer regarding a better procedure for one particular person who may be at risk if an evacuation needs to be carried out. Individual fire risk assessments are contained within the PCP files. Staff made the following comments, “The house is now very well-organised, nice and clean, its a pleasure to work there now, its very well-kept”; “ The decor and atmosphere in the home has improved”; “We have not had a domestic for a while and I feel the service could provide an agency domestic for one to two days a week. This would give us more time to spend with service users.” Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 22 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): 33, 34 and 35. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Staff working in the home have been recruited in accordance with best practice and receive training appropriate to their job role; this makes sure that people are being looked after by suitable staff. There are generally sufficient staff available to meet the health and welfare of people living at the service, but there are still some staff vacancies and temporary staff are being brought in. This means that people are being supported by staff who might not necessarily know all of their individual needs. EVIDENCE: The home is still short staffed and is currently recruiting. This is an ongoing problem; the manager said that she had seen many applicants who were not suitable and that some people had started work and then left the following day. There has been a large turnover of staff in the last 12 months. The lowest number of staff required is a minimum of four people on each shift during the daytime hours. Three people need one-to-one support during the Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 23 day; this is shared out amongst the team to relieve the pressure. There is an ethos of using the minimum amount of agency staff wherever possible, using their own bank staff and borrowing staff from other services where needed. Of the five staff on duty during one of the site visits, only two were permanent; three work at other homes in the group. The staff rotas are only currently being drawn up a week in advance; that particular week showed a minimum of four on mornings and afternoons. Nights are covered by one person awake 8 p.m. to 8 a.m. with one person sleeping-in on call between 10 p.m. and 7 a.m. Staff continue to use the daily planner for use in handover; this outlines the division of tasks and responsibilities throughout the day. Staff meetings minutes were seen; these showed evidence of management setting clear criteria about improving care standards and working as a team. The format for induction training was seen, which appeared to be extensive and thorough. This was echoed in staff surveys, people say they found the induction very interesting and helpful to their job. Staff are enrolled onto National Vocational Qualifications (NVQ) training as soon as possible following induction. The personnel file for one of the most recent recruits was seen. This was very well-organised and contained all of the required documents, demonstrating that the recruitment procedure follows established good practice. The training records for this person showed that they had been provided with Health and Safety at Work training, Food Safety, Fire Safety, Infection Control and training in Equality and Diversity. Training records for one of the seniors was seen. They had achieved NVQ levels 2 & 3, and had also been on Adult Protection Training, Medication Training, Crisis Intervention, Dementia, Epilepsy and training in RecordKeeping, Documentation and Care Planning. There was evidence that staff had read new policies that have been introduced, including recent updates regarding the Complaints Policy, Protection of Vulnerable Adults and the Management and Prevention of Violence and Aggression policies. Staff said, “My training is thorough and meets the needs of the service users”. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 24 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. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home now has effective management and administration in place, although a manager has not yet been registered, so the home runs more smoothly. The support that has been put in place while the new manager settles into her post has been of great benefit to the staff and people living at the home, by providing some consistency. The organisation’s closer monitoring of quality standards is improving outcomes for people living at the home. Record keeping is good, providing evidence of how people are being looked after and kept safe. EVIDENCE: The company has continued to provide a high level of management support to the service, whilst the new manager settles in her post. The acting Business Support Manager, Angela Galloway, continues to work on a daily basis with the Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 25 manager, which has allowed for the much-needed development work to be implemented. No application has been made as yet however to register a manager with CSCI. A deputy manager has been recruited, awaiting CRB and POVA checks before starting work, but a senior post is still vacant. The manager had been with the company for five weeks at the time of inspection and was pleased with their approach so far, finding them transparent and open. She felt she had received good induction and support from other managers. Regulation 26 reports received by CSCI show that senior management have taken seriously the shortfalls that have been identified in recent inspections. Quality audits have been taking place, carried out monthly by internal clinical governance, at the moment until they are happy with the standards. They have also been having an overview of critical incidents that occurred with former residents. Action has been taken to address all of the requirements that were outstanding from previous inspections. Staff performance issues are also being addressed through supervision and management reviews. An example was seen of this by way of a management review of a PCP. An action plan had been developed for the key worker, pointing out the shortfalls within the PCP and giving them a target date by which to address the shortfalls. Staff surveys: staff felt that standards had improved greatly since additional management support has been provided to the home. Comments included: “Since Angela Galloway has been supporting the service I have seen a massive improvement”; “I think Woodhouse Hall has come a long way since Angela Galloway took over. The house is now very well organised”. The company are appointees for residents’ finances. Benefits are paid directly to the company and personal money is requested £20 at a time, put into individual accounts where monthly statements are produced. The “Your Voice” meetings take place monthly (minutes of these meetings were seen) and staff have guidance on how to run these and respond to suggestions made, the “Ask, Listen & Do” strategy. There are three monthly area meetings that residents are invited to attend, no one has yet but the managers are keen to make sure that someone does attend the next one. The company is aiming to produce more policies in an easy read format, with service user involvement. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 26 A variety of statutory and operational records were inspected during the site visits, including: Accident and Incident Reports, Menus, Kitchen Hygiene Records, Medication Records, Policies and Procedures, Complaints Records, Fire Safety Records, Staff Files, Minutes of Staff Meetings, Minutes of Service User Meetings, and Service Users’ Financial Records. The manager was in the process of archiving and weeding out old records so that they could be more organised for the staff. The figures were provided for proposed capital and repair works to be carried out during 2008. Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 27 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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 2 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 Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 28 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 YA13 Regulation 16(2)(m) Requirement The home must provide sufficient staff time, flexibly provided, including evenings and weekends, so that support for people outside the home in smaller groups can take place. There must be a sufficient number and skill mix of permanent staff working at the home to meet the needs of the people who use the service; this includes domestic staff. (Previous timescales of 31/07/07 and 30/11/07 not fully met). An application must be made to register a manager for the service. Timescale for action 31/07/08 2 YA33 18 31/07/08 3 YA37 Care Standards Act 2000, section 11 31/07/08 Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA7 Good Practice Recommendations Staff should identify where people may be able to manage their own finances, with support and tuition, and provide them with the information, assistance and advice they need to make decisions about their own lives. Staff should help people find out about and take up more opportunities for further education, so that they are able to take part in valued and fulfilling activities away from the home. Staff should support people to make and maintain friendships outside the home, including opportunities to meet people who do not have their disability. Person centred plans should include assessments as to whether people can have a key to their own room. 2 YA12 3 4 YA15 YA16 Woodhouse Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Hall DS0000001523.V365202.R01.S.doc Version 5.2 Page 31 - 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. 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