Inspection on 22/05/07 for Woodhouse Hall

This inspection was carried out on 22nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 16 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 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 09/07/2008.

CARE HOME ADULTS 18-65 Woodhouse Hall 14 Woodhouse Lane East Ardsley Wakefield West Yorkshire WF3 2JS Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 22nd May 2007 09:30 Woodhouse Hall DS0000001523.V332755.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.V332755.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.V332755.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 823513 01924 820939 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) www.craegmoor.co.uk 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.V332755.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2006 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. 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 people who use the service. The current scale of charges per week are between £438 and £1,501. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. The last key inspection was carried out in November 2006. A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. Surveys were sent to people who use the service, their relatives and healthcare professionals; responses from the surveys have been included in the inspection report. Seven surveys were received from people who use the service, all of which were completed with help from staff. One inspector carried out a site visit which started at 9.30am and finished at 6.00pm. Feedback was given to the manager at the end of the visit. During the visit the inspector looked around the home, spoke to people who use the service, staff and the manager. Interaction between staff and people who use the service was also observed. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: The home is clean and tidy, and people who use the service are comfortable in their surroundings. People are encouraged to personalise their bedrooms. Each person has a care file that contains some good information about how their needs should be met and the best way to support them. The majority of people attend external day services. Staff said people who attended day care enjoyed going. Day care packages have gradually increased over recent years. Relatives are generally happy with the quality of the service. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: People who use the service are not safeguarded from abuse. They are not always respected and the care practices of some staff are not acceptable. The staff team need to work more effectively to make sure they are all working in the same direction. This was also identified at the last key inspection. Staff need to receive training to make sure they have the skills and knowledge to deal with people’s specialist needs, such as mental health, epilepsy and challenging behaviour. Several people have complex needs and require support with behaviours that challenge. Care plans require more information so everyone is clear how such behaviours should be properly managed. People said the meals were good but because meals provided are not always the same as the menu and this is not recorded, the nutrition and variety is not monitored. The home is a pleasant environment but there were two areas that had an odour and one bathroom did not have proper ventilation. The manager does not have enough support or enough management time to carry out her duties, and this has contributed to the home failing to make very important improvements that were identified at the last inspection. Requirements and recommendations that were identified at this inspection are at the end of this report. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 7 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.V332755.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.V332755.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 & 5 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Future admissions will be carried out more thoroughly because there is a better understanding of how an admission process should be carried out. This will make sure the home can meet people’s needs. EVIDENCE: The last inspection identified that the admission process was not satisfactory and the needs of people who had moved into the home had not been properly assessed. There have been no new admissions to the home since the last inspection so there was very little evidence for many aspects of this outcome group. It was not possible to assess whether the requirements which related to the admission process made at the last inspection had been met. These standards will be looked at the next inspection. After the last inspection, the manager said she was clear that each person must be fully assessed before they move into the home and the necessary documentation must be available at the home. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 10 The last inspection identified that some people had not been given terms and conditions and there was no information about the cost of fees. The manager has now issued terms and conditions and provided information about fees. Staff have discussed these with people who use the service or their relatives. This will make sure people are clear about what is expected of them and what they can expect from the home. The Statement of Purpose contained specific details about the number and gender of people who use the service and staff members. Some of the information was out of date. The manager agreed to up date the information and make it less specific so they would not need to up date the document every time there was a change at the home. This will make sure people have up to date information about the home. Woodhouse Hall DS0000001523.V332755.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 & 9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The care planning process works for identifying basic care needs but it is not central to identifying how more complex needs should be met. Some staff have not followed care plans and others are unsure how to support some people who use the service and this has led to confusion and inconsistent care approaches. EVIDENCE: Three people’s care records were looked at. There was good information in care plans and there was some good guidance on how individual needs should be met. Care plans identified the support people required with personal care, going out into the community, diet and domestic tasks. There was information about likes and dislikes. Care plans had been reviewed monthly. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 12 Some information was missing from care plans and staff had not followed some guidance that was available. This has been written in more detail under the complaints and protection section. The registered provider was in the process of introducing new person centred care plans, which focus on individual needs and involving people who use the service. Several people have complex needs and require support with behaviours that challenge. Staff dealt inappropriately with one person during the inspection; detail of this is in the complaints and protection section of this report. Staff talked about management of behaviours but talked about using different management techniques for the same behaviour. Comments were made about inconsistencies amongst the staff team and difficulties in managing some behaviour. Care plans did contain guidance but some of this was quite general. The manager and deputy agreed to talk to staff to find out which care plans required more information. Three areas were identified at the inspection; two related to food issues, one related to removal of clothes. The home has some measures in place that restrict people’s rights. Restrictions include access to the kitchen and a locked front door. Care files contained ‘infringement of service user rights’ documents that identified where rights were limited. The manager said as part of the new care planning process, restrictions would be reviewed to make sure they have been assessed individually. This had been identified as area for improvement through the clinical governance visits. Woodhouse Hall DS0000001523.V332755.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, 14, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given opportunities to engage in recreational activities and go out into the community although there is room for development in this area. Relatives are generally happy with the quality of the service. EVIDENCE: Two relative surveys were returned, these were generally positive about the standard of care that is provided and the following are a sample of responses and comments: • The care home usually meets the needs of the people who live there • Care staff have the right skills and experience • The care home helps their relative keep in touch and they are always kept up to date with important issues • The care home usually meets the different needs of people Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 14 • • • Staff do a wonderful job to the best of their ability. Managing the rest of the work must be very hard. Extra staff when needed would be good for all concerned The care home is spotless and the people are very well cared for It would be better if there were more staff to take people out Seven surveys from people who use the service were returned; staff helped them to complete the forms. Each survey stated they could do what they wanted during the day and at weekends, six stated they could do what they wanted on an evening, one stated they could not. The majority of people attend external day services. Staff said people who attend enjoyed it. Day care packages have gradually increased over recent years and this has improved the quality of life for all those attending. One person talked about an activity programme that they had done with their keyworker. They said it needed updating because they had recently changed their day care attendance. They said everything was ok. One person said they were going to the hairdressers, looking forward to going on holiday in June and again they said everything was ok. People who use the service and staff talked about different activities that were available at the home. These included arts and crafts, baking, knitting, sewing. They also talked about going out for walks to the local shops and going out on the minibus. On the day of the inspection, an external facilitator was taking a motivation session, with exercise and group discussions. Comment was made that sometimes it was too busy and not possible to provide recreational activities. The daily records for three people, covering a four-week period, were looked at. Lifestyles varied greatly. People that attend day services were generally quite active, others had much less activity in their life. Each person had gone out with staff support. The manager and deputy said some people did not want to participate in in-house activities but agreed that there could be more social outings for those people. The person who was responsible for co-ordinating activities had recently left and it was acknowledged that in house activities might have dwindled as a result. The manager said she would give another member of staff this role. Person centred planning should identify the level and type of activity that each person would like to do, therefore once these are introduced staff should have more guidance about activity programmes. One healthcare survey stated the house was quite noisy during day. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 15 People who use the service said the food was nice. Menus were looked at and these were varied and nutritionally balanced. A food record sheet was in the kitchen but this had not been filled in consistently. For example the previous evening fish had been on the menu but sausage and mash was served. This had not been recorded anywhere. It is not possible to monitor variety and nutrition if meals are not properly recorded. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 16 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 & 20 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staff consult healthcare professionals but they do not have the skills or knowledge to deal with specific conditions of people who use the service. Healthcare professionals are not confident that healthcare needs are always met. EVIDENCE: Care plans had information about how personal care needs should be met, which included bathing, dressing, eating, preferences for bedtimes and times for getting up. Two healthcare surveys were returned. The following responses and comments were included: • • • Healthcare needs are usually/sometimes met Individuals’ privacy and dignity are usually/sometimes respected The service usually/sometimes supports individuals to live the life they choose DS0000001523.V332755.R01.S.doc Version 5.2 Page 17 Woodhouse Hall The primary care need of people who use the service is learning disability. They also have other specialist care needs, which includes mental health and epilepsy. Only a small percentage of the staff team had received training in these areas. Healthcare surveys stated that staff required additional training in specific areas. One survey stated that staff sometimes have the skills and experience to support people. One survey stated never. Each file had a health record section. This provided details of any recent healthcare appointments. Records confirmed people had seen different healthcare professionals in the last few months including dentists, chiropodists, nurses, GPs and specialists. Individual weight records were also maintained. Staff were concerned about the deterioration in one person’s health. They had closely liaised with the GP and recorded details of all contact. The administration of medication was observed and this was administered appropriately. Medication and medication records were looked at and the amount of medication and the records corresponded. Medication storage was looked at and the medication was well organised. Woodhouse Hall DS0000001523.V332755.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 & 23 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are not safeguarded because staff use inappropriate practices to control people and they have not received adequate training. EVIDENCE: The manager said the home had not received any complaints within the last twelve months. The home has a complaint’s book to record any complaints. A whistle blowing policy for staff and the complaints procedure were displayed in the main office. CSCI contact details were included in the complaints procedure. All surveys from people who use the service stated they know who to talk to if they are unhappy. Four had stated they would talk to the manager. At the last inspection it was identified that some staff do not treat people who use the service with respect. Again, this inspection identified that there were similar problems. Poor practice was also observed at the last inspection and again at this inspection. On the morning of the inspection, the inspector observed one person eating another person’s breakfast and drinking their tea. This happened on three occasions. The cereal was replaced twice but when the person, who had their breakfast eaten by someone else, asked for another cup of tea, they were told to wait until they had finished their cereal. Staff were aware of the problem but Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 19 did not respond appropriately or prevent it from happening. The manager observed some of this practice and identified that it was unacceptable. The staff communication book and daily records were looked at. These contained inappropriate statements that related to practices between staff and people who use the service. A person was incontinent in bed and staff had told them they would not remake their bed until they had a shower, another person was woken at 5.30am because they had previously made a mess in their room at that time. One person had been taken to bed early so another person could have some peace. A senior staff member had written that staff should wake one person ‘at say’ 12.00 and 3.30 and then hopefully the nappies will work for everyone. All these practices contradict the guidance that is written in the care plans. Other statements were also derogatory and inappropriate. For example a person who uses the service had been referred to as a nightmare, others were referred to as grumpy. One staff had written ‘get ready for kick off’. When asked how the care service could improve one healthcare survey stated staff attitudes and their impact on people who use the service. The manager said she was concerned about staff attitudes because some staff had mentioned this; she said they were saying enough to raise concerns but not enough to take any action. Since the last inspection, there has been an allegation of inappropriate management by a staff member towards a person who uses the service. This was dealt with through the disciplinary process. An investigation concluded that there had been a delay before staff reported concerns and whistle blowing training should be given to staff. The manager thought the training had been provided in February but at the inspection it was discovered that the training had not gone ahead. Whistle blowing was discussed at a staff meeting in January 2007. Concerns have also been highlighted that restraint was used inappropriately and this resulted in a person who uses the service suffering from unnecessary bruising. The registered provider was still investigating this at the time of the inspection. One of the three care records stated that staff must use specific restraint techniques. Only three staff had received the correct training, therefore it would not be possible to use the technique unless two of the three staff were on duty. This poses a risk because staff cannot follow care plan guidance because they have not received suitable training. Woodhouse Hall DS0000001523.V332755.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, 26, 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is generally pleasant, well maintained and people who use the service are comfortable in their surroundings EVIDENCE: A tour of the building was carried out. All communal areas and bathrooms were visited and the majority of bedrooms were seen. The home was clean and tidy. Decoration, furniture and furnishings were of a reasonable standard. New carpets/flooring had been fitted in most of the communal areas. The garden is enclosed and this is an area that people who use the service freely access. In the ground floor toilet/shower room there was an odour and the air was humid; it was unpleasant after spending a few minutes in the room. The extractor fans in the ceilings had been replaced but these were only small fans and there was no other form of ventilation. There was also a strong odour in one bedroom. A device to help eliminate odours has previously been used but Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 21 it was broken at the time of the inspection. The manager said they were waiting for it to be repaired. Most bathrooms did not have toilet roll or paper hand towels. The manager said some people who use the service removed the paper. A system must be introduced to make sure people who use the service have access to toilet roll and hand drying facilities. Bedrooms were personalised and each room had a lot of items that reflected individual preferences. Posters, pictures and photographs had been mounted on walls. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. Woodhouse Hall DS0000001523.V332755.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): 32, 33, 34, 35 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home will not improve the service or succeed in providing person centred care unless they address the problems amongst the staff team and change the general culture. EVIDENCE: All surveys from people who use the service stated staff treated them well and they listen and act on what they say. Staff had helped them complete the surveys. There has been a high turnover of staff in the last few months. At the time of the inspection, the manager had a new deputy but no senior staff. Four care staff had recently started working at the home. It was acknowledged that when a home has an influx of new staff this can be difficult because it takes time for everyone to settle in. At the time of the visit the manager was completing the rota on a week-byweek basis to make sure staff were available. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 23 The last inspection identified that the team had not been working well together and not all staff were pulling in the same direction and this had led to tensions amongst the team. At this inspection the same problems were evident. The staff communication book highlighted that there were problems and obvious conflict amongst the staff team. Written comments to each other were inappropriate and unprofessional. One statement used an offensive term and was derogatory towards people who use the service. Another person had written ‘like most things I haven’t been made aware’. The manager and deputy said the last few months had been very difficult. They said there had been problems amongst the staff team and they had tried to address the problems. They had both written in the staff communication book that it should only be used to pass on information and not for personal comments. The manager and deputy said there had also been problems because some staff were not fulfilling their duties. For example failing to complete food records and food temperatures. The manager said she had spoken to the area manager and they were looking at how this should be managed. They were also introducing a daily planner that identifies which tasks staff should complete. Training records for three staff were looked at. One staff who had recently started work at the home had completed four training sessions and was booked for more training The other staff had completed all the mandatory training which includes food hygiene, fire safety, moving and handling, first aid, adult protection, and health and safety. One staff member that recently started work at the home confirmed they had attended an interview and all the relevant checks had been carried out. They had only started work a few days before and were in the early stages of their induction programme. They did not have an induction workbook because these are apparently not issued until after employment commences. Two staff had transferred from other homes within the organisation, although one had only worked for the organisation for a short time. They both said they had started an induction but their induction workbooks were not available at the home. One staff had not finished their induction even though it was several months since they started working for the organisation. Recruitment records for three staff were looked at and all the relevant information was available. Records for one person who transferred and a new employee were not available. The manager said the new employees records Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 24 were being sent through from the organisation’s head office and she was chasing up the other records. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 25 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, 38, 39, 41 & 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The manager has not had the right support or time to carry out her duties and the management of the home has suffered, placing service users at risk. EVIDENCE: The manager said she had completed several units of the Registered Manager’s Award and even though she has had to extend the timescale for completion, she hopes to achieve this by the end of December 2007. In addition to staff shortages the home has gone through various staffing and management changes in the last few months. A new deputy manager was in post. There should be two senior staff but both these posts were vacant. There Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 26 have also been several different area managers. These changes have resulted in the manager not having enough management support. During the day people who use the service regularly came in the office to see the manager. They were seen to want to spend time with her, laugh and joke with her and asked for advice. It was evident that the manager had a very good relationship with people who use the service. One health care service stated to improve the service effective support should be provided to staff and especially managers. Another survey stated good management could improve the service. The manager said she could see a light at the end of the tunnel because the home has several new staff and this should ease the pressure on everyone else working at the home. The staff communication book was being used to record personal information about people who use the service. The book contained information about continence, healthcare and personal care. Communal files should not be used because it does not maintain confidentiality. The organisation has a clinical governance team that periodically visit the home and look at certain quality issues. They had visited the previous day and identified that some records were not being completed properly they had also identified that some care plans required more guidance. Once a month the provider visits the home and looks at the general conduct, these visits are called Regulation 26 visits. The manager of another home had visited the home and completed these visits. The last two reports were looked at during the inspection because they had not been sent to the Commission. Previous copies had been sent. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. Woodhouse Hall DS0000001523.V332755.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 2 2 2 3 X 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 1 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 1 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 2 2 3 X 2 3 X Woodhouse Hall DS0000001523.V332755.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. 2. Standard YA1 YA6 Regulation 6 15 Requirement Information in the home’s statement of purpose must be correct Care plans must identify how people’s complex needs should be met. This relates to management of behaviour. Nutrition and variation of meals must be properly monitored. Staff must receive training and guidance that equips them with the skills and knowledge to deal with specific conditions of people who use the service. This relates to mental health and epilepsy. People who use the service must be safeguarded from abuse by ensuring staff treat people with respect and staff follow care plan guidance. All staff who may have to use restraint must be appropriately training to use the correct techniques. All staff must receive appropriate training to make sure they understand safeguarding adults policies and procedures, which should provide them with information about the types of DS0000001523.V332755.R01.S.doc Timescale for action 31/08/07 30/09/07 3. 4. YA17 YA19 16 12 30/06/07 31/08/07 5. YA23 18 30/06/07 6. YA23 18 31/07/07 7. YA23 13 31/07/07 Woodhouse Hall Version 5.2 Page 29 8. 9. YA24 YA30 23 16 abuse and the whistle blowing policy. The ground floor bathroom must be appropriately ventilated. The home must be free from offensive odours. (The timescale of 28/02/07 was not met) Bathrooms must be stocked with toilet rolls and hand towels. Staff must have the competencies and qualities, and be able to work together as a team to meet the needs of people who use the service. (Timescale of 28/02/07 not met) There must be a sufficient number and skill mix of staff working at the home to meet the needs of the people who use the service. Staff records must be available in the home. All new staff must complete the induction programme. The registered manager must complete a relevant management qualification. (Timescale of 30/04/07 not met) The manager must be given sufficient time to carry out her management duties. The registered provider must provide adequate support to ensure the management of the service is satisfactory. 31/07/07 31/07/07 10. YA32 18 31/08/07 11. YA33 18 31/07/07 12. 13. 14. YA34 YA35 YA37 17 18 9 31/07/07 31/08/07 31/12/07 15. YA37 10 31/07/07 16. YA38 10 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000001523.V332755.R01.S.doc Version 5.2 Page 30 Woodhouse Hall 1. 2. YA14 YA41 There should be more opportunities for people using the service to engage in recreational and social activities. Staff should record personal information about people who use the service in their personal files to make sure confidentiality is maintained. Woodhouse Hall DS0000001523.V332755.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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.V332755.R01.S.doc Version 5.2 Page 32 - 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!