Inspection on 16/03/06 for Woodhouse Hall

This inspection was carried out on 16th March 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodhouse Hall 14/04/08

Woodhouse Hall 15/10/07

Woodhouse Hall 22/05/07

Woodhouse Hall 28/11/06

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 09/07/2008.

CARE HOME ADULTS 18-65 Woodhouse Hall 14 Woodhouse Lane East Ardsley Wakefield West Yorkshire WF3 2JS Lead Inspector Karen Westhead Unannounced Inspection 16th March 2006 09:40 Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 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.V286099.R01.S.doc Version 5.1 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.V286099.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodhouse Hall Address 14 Woodhouse Lane East Ardsley Wakefield West Yorkshire WF3 2JS 01924 823513 01924 820 939 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) J C Care Ltd Mrs Vikki Harratt Care Home 13 Category(ies) of Learning disability (13), Physical disability (13) registration, with number of places Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: Woodhouse Hall is owned by J C Care, which is a subsidiary of Craegmoor Health Care. The home is run by the registered manager, Ms Vicky Harratt. The service is registered to provide care and accommodation for up to thirteen adults who have a learning disability. So as not to have residents sharing a bedroom, the maximum number of residents being cared for currently is eleven. Ten permanent residents and one respite client. 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 second 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, an area of 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 residents. The home provides staff over the twenty-four hour period and a senior member of staff is available at all times. The organisation also provides on call arrangements, out of hours. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the Commission for Social Care Inspection (CSCI) is required to undertake a minimum of two inspections of all regulated care homes. This was the second inspection of this home for the 2005/2006 inspection year. One inspector undertook the inspection, which was unannounced. The visit started at 9.40am and finished at 2.30pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. The last inspection of this service was on 1st December 2005. At that time six requirements and one recommendation were highlighted. Four of the requirements have now been met. One remains outstanding until a refurbishment is completed to the kitchen (due to take place in early April). The other involves cooperation from a specific resident, about financial arrangements. The resident has recently been unwell and spending time in hospital for treatment. The manager is aware of the action required and confirmed this would be done when appropriate. During the course of the visit, the inspector spent a large proportion of time speaking with residents, staff members and the manager. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. All staff on duty were spoken to and observed carrying out their work. Individual and group discussions were held with residents. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. One comment card asks questions about the inspection process and the way the inspector carried out her duties. After completion these are returned to the CSCI. Feedback about the findings from the inspection were given to the manager at the end of the visit. What the service does well: Staff make an effort to put residents first. It was clear from the evidence gathered on the day that residents are able to make informed choices about their lives. Those residents with difficulties with communication or understanding are supported. Staff have been able to adapt their working practices to make sure everyone has a voice. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 6 Staff work to provide an environment where residents can develop at their own pace. Staff involve residents as far as possible in setting out their plan of care, which aim to achieve their expectations. Risk assessments are designed to minimise risk and not impose unnecessary restrictions on what people can do. Activities and training for residents is seen as an important part of their lives and staff support residents in this area. The home has good adult protection procedures and staff understand what to do if they observe or receive a report of inappropriate behaviour. The home gives training and support for staff, which enhances and develops their skills and abilities. Recruitment and selection procedures are in place to make sure suitable people are appointed and that residents are protected. What has improved since the last inspection? 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. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 7 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.V286099.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Prospective residents are fully assessed before coming to stay at the home. They are given an opportunity to visit Woodhouse Hall before making a decision about moving in. The assessment is used to make sure the home can meet the resident’s needs. All residents have a contract with the home and know what services are to be provided. EVIDENCE: The statement of purpose and resident guide is informative and provides the reader with an overview of what Woodhouse Hall provides. Residents with limited understanding have access to information in different formats, including pictures and symbols. The home has the necessary procedures and strategies in place to successfully admit and discharge residents. During the visit the inspector spent a good proportion of time talking and interacting with residents. Residents are enabled to use all the facilities in the home and looked comfortable in their surroundings. The staff group know the residents well and they pick up subtle changes quickly. In particular, residents who have limited communication and understanding. Staff are sensitive and are able to pick up nonverbal triggers, Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 9 which can indicate discomfort, unhappiness or illness. Therefore enabling them to take appropriate action promptly. The inspector gained the impression from observing and talking to residents that they were satisfied with the care and attention provided. No complaints were raised with the inspector during the visit. The inspector viewed a random selection of files. Those seen contained a statement of terms and conditions, setting out the fee paid and the services to be included. Work has been done to make sure all the care plans include up to date information about each resident, including risk assessments. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 The care files seen were well ordered and provided a chronological record of the care being delivered. EVIDENCE: The files examined were all made up in the same format, which made it easy to cross reference information. The care plans are checked by a senior person from the organisation on a monthly basis. Information e.g. contact with family; nutrition/dietary intake and health related matters had been amended to reflect changes in the care residents were receiving or their current situation. Residents are helped to make choices about their lives. Residents who could communicate verbally gave an account of their experiences in the home and talked about their wishes and aspirations. Daily recording sets out the care provided in accordance with the overarching care plan. Some staff were better than others at recording their actions in response to care needs. However, as a record it gave the necessary information. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 11 Since the last inspection, risk assessments have been reviewed and altered as required. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15 and 17 Residents enjoy mealtimes. Staff encourage residents to become involved in the tasks in the kitchen. Residents have appropriate support from staff, outside agencies and other professionals in order for them to lead a fulfilling lifestyle inside and outside the care home. Educational, social and recreational activities provide a good balance and allow the opportunity for personal development. Family links are maintained and residents are able to develop intimate and personal relationships with people of their choice, where appropriate. Assistance and guidance is provided in these areas. EVIDENCE: On the day of the visit, some residents were planning to go out on a shopping trip, others were attending day services and some residents had been out in the house vehicle. The inspector observed the interactions between residents and staff. Staff listened to the wishes of residents and provided clear guidance about the plans for the day. The inspector gained the impression that staff Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 13 were keen to make sure all residents were provided with appropriate activities and were mindful of the need to include those who were less vocal. Residents have their meals in the dining area. Staff provide assistance and prompting as required. For safety reasons, the kitchen is kept locked. However, it was evident during the visit that residents are offered regular drinks and snacks or staff respond to requests at other times. The lunchtime meal consists of a variety of snacks and the main meal of the day is served at teatime when most residents are at home. The menu plans seen included a range of dishes. Budgets for food provision were said to be adequate and the weekly shop is done at a large supermarket. The inspector observed the serving of the meal at lunchtime. This was well organised and residents were given a choice of snack, time to eat their meal and time to chat at the tables afterwards. Written evidence on file and in the daily notes showed that residents were maintaining outside links and being given help, reassurance and assistance to engage in meaningful and fulfilling relationships with family and friends. Information recorded on the daily events sheet and activity register showed there is a diverse range of structured activities for residents to take part in. Activities include further education and recreational events. Residents, who were able to share their experiences, confirmed they were satisfied with the levels of activity provided. Residents are involved in light household tasks and this is distributed according to individual skills and abilities. Residents require escorting when out of the home. Residents with specific and complex needs are provided with specialist support from other agencies if required. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 In general the care files seen gave a good indication of the level of care each resident receives. Support around health needs is good. Medication records were being appropriately maintained. EVIDENCE: Since the last inspection there has been an improvement in the filing of accident and incident reports. The layout of care plans makes it possible to see how individual goals are to be met. The information identifies how much support is required to maintain people’s wellbeing and health. Staff access information from a variety of agencies and use the help of other professionals to make sure residents receive the best advice and treatment. The home has good links with the local doctors surgeries. All medication is delivered in pre-dispensed packages. The record of medication was found to be up to date. The training record indicated that all staff have received training for the administration of medication. Some staff have had repeat training to make sure they are competent to carry out this role. The medication file includes useful supplementary information of drugs in use. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 15 None of the current resident group takes responsibility for taking and storing their own medication. This decision is determined by a risk assessment and if appropriate a discussion with the resident. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents are not fully protected from financial abuse. A significant number of incidents, resulting in a form of restraint being used, is an ongoing matter for the manager and organisation to consider. This issue must be continually monitored to ensure the use of restraint is reserved as a last resort and used appropriately. Concerns and complaints are dealt with promptly and appropriate action is taken to ensure the welfare and protection of residents. EVIDENCE: At the last two inspections it was noted that the banking arrangements for one resident had not been correctly up dated since the current company had taken over, which amounts to a considerable amount of time. It was agreed that this would be dealt with as a matter of urgency. However, it is acknowledged that the resident involved has not been well enough to deal with the matter. Therefore a deferred timescale has been applied. One adult protection matter has been investigated since the last visit. This resulted in a member of staff being given a final written warning. One complaint has been made and addressed within the home. Records were examined to check the number of times restraint has been used. All incidents and accidents were recorded in full. It was noted that one resident has been subject to a significant number of restraints. This must be monitored closely and if necessary the resident reassessed. It was evident that written guidance from the resident’s consultant is being followed and staff are consistent in their dealing with any given situation. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 and 29 Work is still required to the kitchen area, catering facilities and shower room to ensure standards are maintained. A scheduled refurbishment in April will take these into account. The home is well adapted to cater for the needs of the resident group. EVIDENCE: All the communal areas were seen. These were decorated to a satisfactory standard and were furnished appropriately. The kitchen area and shower room are to be overhauled in April. The residents and staff are going away to Cumbria for two weeks. During which time the contractors are moving in and completing the work. Levels of cleanliness were found to be good. Externally, there are gardens to the rear and front of the home. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 36 The number of staff available on each shift is adequate. Formal supervision is provided for all staff and records kept of the key points talked about. Routine training is given to allow staff to update their skills and knowledge. EVIDENCE: Since the last inspection there have been no changes in the staff team. There is always a senior member of staff on duty to support the care staff. On call arrangements are well organised. Two members of staff confirmed they receive regular input from senior members of staff. They said the training they were given equipped them to carry out their work. The staff on duty were seen to reply to residents requests in a clear, competent and patient manner. Staff on duty said they had regular supervision sessions, which included looking at individual care files, training needs and working practices. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 and 43 The home has a system in place to check out levels of quality. Fire safety procedures ensure the welfare of residents is not compromised. EVIDENCE: At the last inspection, the fire record was not being kept up to date and did not reflect the checks being carried out. This has now been resolved. The organisation has initiated a quality assurance scheme. This has yet to be introduced in the home. The organisation has adequate insurance cover in place. Senior managers within the organisation have a business plan and managers in the home are expected to contribute to this. Managers present their budget forecasts and discuss the needs of each home as part of the overall financial plan. During the course of the visit no problems with highlighted regarding the financial viability of the home. Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 20 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 X 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 x 26 3 27 3 28 x 29 3 30 x STAFFING Standard No Score 31 3 32 x 33 3 34 x 35 x 36 3 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 X 12 X 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x X X 3 X X 3 3 Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 21 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 12 Requirement The registered person must make sure that arrangements are in place to protect the financial arrangements for residents. This is outstanding from the previous inspection on 27th January 2005 and 1st December 2005. 2. YA24 23 The registered person must make sure the equipment and facilities in the kitchen are safe to use and are in working order. Areas should be kept in a state, which allows proper cleaning. 30/05/06 Timescale for action 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodhouse Hall DS0000001523.V286099.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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.V286099.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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