Inspection on 28/11/06 for Woodhouse Hall

This inspection was carried out on 28th November 2006.

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 no outstanding requirements from the previous inspection report, but made 15 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 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 28th November 2006 09:45 Woodhouse Hall DS0000001523.V321095.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.V321095.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.V321095.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 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) 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.V321095.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 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 service users sharing a bedroom, the maximum number of service users being cared for currently is eleven. Ten permanent service users 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 service users. The current scale of charges per week are between £429 and £1,388. Woodhouse Hall DS0000001523.V321095.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 care services are inspected. They 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 March 2006. A questionnaire was sent to the home and should have been completed and returned by the 1st December, however this had not been received by the 12th December, therefore information that would ordinarily be used as part of the inspection process was not available. One inspector carried out a site visit which started at 9.45am and finished at 6.00pm. Feedback was given to the registered manager two days after the inspection. During the visit the inspector looked around the home, observed staff and service user relationships, spoke to service users, staff and the registered manager. Service user plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: Each service user has a care file that contains some good information about how their needs should be met and the best way to support them. The care plans are reviewed regularly. Service users have opportunities to join in recreational activities in the home and were enjoying a motivation session on the day of the inspection. They enjoy the meals, which are varied and nutritious. Bedrooms were personalised because they had a lot of items that reflected individual preferences. Posters, pictures and photographs had been mounted on walls. This demonstrates that everyone is encouraged to make their rooms homely. The manager had identified where there were some problems and had started to deal with these. Regular health and safety checks are carried out. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 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.V321095.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, & 5. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The admission process is poor and service users needs have not been properly assessed. This means that their needs may not be met. EVIDENCE: Two service users have moved into the home in the past six months and these were on an emergency basis; these admission processes were looked at. One admission had taken place a few days before the inspection. There was no admission information for either of the service users. Care management/social work assessments were not available and the home had not completed assessments. Staff and the manager said only limited information was available from previous placements, although the placements were with the same organisation. The national minimum standards state that service users placed in an emergency are fully assessed. There was no evidence that the placement had been discussed or agreed with service users or professionals. One service user was unhappy with the placement and staff and the manager said uncertainty had contributed to some of the unhappiness. The manager said this had been discussed with health care professionals but there was no evidence to support this. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 9 The two recent admissions did not have terms and conditions in their files and there was no information about the cost of fees. Other service user files did have terms and conditions and these were written in plain English, although there was still no information about the cost of the placement. A list of charges was obtained from the organisation. The manager agreed to provide the two service users with terms and conditions and provide service users or their representatives with details of the fees. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care records contain a lot of information about how service users’ needs should be met but staff need to work as a team to make sure care plans are implemented and needs met. Service users’ rights are sometimes restricted and systems are in place to record what these are but because they are not correctly applied, service users’ rights are not protected or respected. EVIDENCE: Care records for three service users were looked at. There was good information in care plans and there was guidance on how individual needs should be met. For example ‘enjoys doing laundry and ironing- prefers to do this on an evening’, ‘allow to use own words to describe without intervention’, ‘staff to prompt to change clothes’. Care plans had been reviewed monthly and details of changes to care needs were recorded. This is good practice and demonstrates that care needs are reassessed. Care files had guidelines to assist staff. There was specific guidance on the best way to support individual service users. The information was not dated Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 11 therefore it was difficult to establish if it was current. A list of service user’s likes and dislikes was in each file. Two service users talked about what they liked doing and information in their care record reflected this. Risk assessments had been completed and some information was good but other information was from previous placements and there was no evidence to confirm that the risks had been reassessed. An assessment for one service user identified that extra measures for fire safety should be considered but there was no evidence this had been done. Risk assessments that related to aggression were specific, risks were identified and there was clear guidance on how these should be managed. The home has some measures in place that restrict service users’ rights. Service users files contained ‘infringement of service user rights’ documents that identified where rights were limited but these were not being properly used. A senior staff had signed one form as the service user’s representative but this was the same senior staff that had made the decision to impose the restriction. This document had a review date for the beginning of October but this had not taken place. Another form also had a review date for the middle of October and again, this had not been done. Staff confirmed that the restrictions no longer applied but the documentation did not reflect this. The principle of the document is good but these should only be used after careful consideration and consultation has taken place. There were practices observed during the day that were unacceptable and they limited the rights of service users. One service user repeatedly asked for certain foods and was told they would get some if they sat down. However, when the service user sat down they were not given the food as promised. Another service user asked several times throughout the day to go to the shop and was given various reasons why this was not possible, although some of the reasons were not valid. The hot water in one service user’s room had been turned off and staff gave different reasons for this. The manager was unaware the water was switched off and arranged for it to be turned back on. Good practices were also seen during the day. Service users obviously enjoyed spending time with staff and were relaxed when talking to them. They freely entered the office and asked staff and management about various things. Staff took time to find out information and then explained it in detail. One service user was upset and staff were seen to be sympathetic and spent time with them until they felt better. The kitchen is locked for health and safety reasons and service users can only access it when staff are present. Assessments have been completed for the restricted access and the manager said service users are told about this when they move in. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 12 Staff said bedtimes and times for getting up are flexible. Daily records confirmed that service users had gone to bed when they were ready. Some staffing issues which have affected the standard of care in the home were identified at the inspection. Details are in the staffing section of this report. Woodhouse Hall DS0000001523.V321095.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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recreational activities are generally satisfactory and an increase in external day service packages has improved the quality of life for service users. EVIDENCE: Staff and service users talked about different activities that were available at the home. These included cooking, painting, sewing, and recently they had made door signs and picture frames. They also talked about going out for walks to the local shops. On the day of the inspection, an external facilitator was taking a motivation session, with exercise and group discussions. Service users were joining in the session, and said they enjoyed it. The home has a minibus and several service users went out for a ride on the day of the inspection. A record of outings was available but there were very few entries. The deputy manager said staff had not filled this in each time an outing had taken place. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 14 Staff said service users would benefit from having more opportunities to go out into the wider community, and they suggested trips to the coast and bowling. The manager said it was harder to organise outings now more service users attended day services but agreed there was room for improvement. Staff said all service users go on holiday at least once a year, this year everyone had gone to Cumbria while the house was being refurbished. The organisation has three holiday cottages and service users can access these. Staff said it was not appropriate for some service users to perform household tasks because of their complex needs. They had agreed at a recent staff meeting that where it is appropriate more opportunities should be given, to service users, to work alongside staff to develop independent living skills. Each service user has a day allocated to clean their bedroom and do their laundry. However, staff predominantly do the work and this was where staff felt independence should be encouraged. Two service users talked about doing their laundry and helping with cooking. The majority of service users attend external day services about three times a week. Staff said the introduction of day care, which has taken place over the last couple of years, has improved the quality of life for all those attending. The majority of service users have keys to their rooms. Service users said the food was good and they had enough to eat. Staff are responsible for preparing and cooking the meals and they generally follow the menus. Any changes are recorded on the food records. The menus were varied and nutritious. Each morning staff ask service users what they want for lunch, which they can choose from a list. Service users had a statement in their file which they had signed. It confirmed that they agreed to promote independence and referred to being empowered. This statement was complicated and the manager should look at using plain English so it is easier to understand. Woodhouse Hall DS0000001523.V321095.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there was evidence that service users were attending healthcare appointments, there was not a satisfactory system in place to monitor healthcare needs and this could result in some healthcare needs not being met. EVIDENCE: Care plans had information about how personal care needs should be met. For example ‘requires prompting to change clothes’ and ‘prefers to have a drink on a morning before getting dressed’. Staff said service users regularly receive healthcare services and this includes dentist, chiropodist and GP. Care records confirmed that service users had attended well-being health appointments. Each service user had healthcare sheets but these were not up to date. For example dental, optician and chiropody records for one service user were blank and another service user’s record stated they had not seen a chiropodist since 2003 or an optician since 2004. Staff and the manager talked about involvement with community nurses and psychologists but again this information was not in service user files. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 16 Service users’ had been weighed monthly and a record of weight loss or gain was noted. One service user self medicates although staff observe. A risk assessment and care plan was not available but there was an assessment from a previous placement that raised concerns about self-administration. Care plans do not generally contain guidance about medication. There should be details of personal preference for administration and information that consents to care workers administering medication. Medication records were looked at and were completed correctly. One service user had been prescribed antibiotics. The number of tablets prescribed and the number of tablets remaining corresponded with the medication administration record. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory procedures are in place and service users will talk to staff and management but they are not safeguarded from abuse because satisfactory systems are not in place to monitor occasions when staff use restraint. Service users’ finances are safeguarded. 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. Service users said they talk to the staff when they were unhappy. The manager was fully aware of the adult protection procedure and how to report any allegations of abuse. Staff have attended adult protection training. The last inspection identified that a significant number of incidents, resulting in a form of restraint were being used, and this was an ongoing matter for the manager and organisation to consider. At this inspection staff said they often used low level holds to calm situations, and this was two, three or four times a week. Each time a low level hold is used an incident form should be completed. The number of incident forms completed did not reflect the number of times described by staff. The manager Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 18 and deputy manager said that staff were regularly told to complete all the relevant documentation but this did not always happen. The manager must look at how to improve the monitoring and recording of incidents when holding techniques are used. Daily records were completed regularly but some of the information was not accurate. For example there had been an incident between two service users on the morning of the inspection but this was not recorded. The last inspection identified that the banking arrangements for one service user was not satisfactory. This has now been sorted and the service user has their own bank account. Financial records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally pleasant, well maintained and service users are reasonably comfortable in their surroundings but some health and safety issues need to be addressed to make sure everyone is safe. 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. The garden is enclosed and this is an area that service users freely access. In April 2006, all areas of the home were decorated. New dining room furniture had been delivered on the morning of the inspection. Staff said the environmental improvements were good for everyone at the home. In the toilet/shower room there was a strong odour and the air was humid. The extractor fans in the ceilings were not working and there was no other form of ventilation. The maintenance person said a maintenance company had been contacted about the problem but they had not yet responded. The Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 20 maintenance records identified that a problem with the extractor fans was highlighted in September. At the feedback session the manager said new extractor fans were on order. There was also a very strong odour in the toilet on the first floor. The room, which has no form of natural ventilation, was very small and the door could not be fully opened because of the hand sink. The odour was very offensive and it would be difficult for anyone to use the room without being overpowered by the smell. Temperatures of hot water outlets were tested during the inspection. In two baths the water was too hot, the temperature of water from the hot water outlet in one bath exceeded 48°c and the other exceeded 49°c. The temperatures were set too high but the temperatures also apparently fluctuate because of the boiler. This is a potential risk and appropriate action must be taken to ensure the temperature remains at a safe level. When the problem was identified at the inspection, the manager contacted the area manager and agreed to ensure temperature settings were reduced. The bathroom flooring was not fitted around the vanity units in two of the bathrooms and floorboards were exposed. This was apparently an error when the new bathroom suites were installed. The manager said this problem was being addressed. Bedrooms were personalised and each room had a lot of items that reflected individual preferences. Posters, pictures and photographs had been mounted on walls. The service user that moved in a few days before the inspection had personalised their room which included putting posters and flags on the wall. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 21 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, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team have recently gone through a period of unsettlement which has led to some disruption. Most staff have good attitudes but some staff do not treat service users with respect. EVIDENCE: The home has a low turnover of staff and most staff have worked at the home for a number of years. Staff at the home had a good knowledge of the service users and were able to provide information about individual likes and dislikes. Staff raised concerns about the staffing levels. Four staff are on duty during the day and their duties include transporting service users to and from day care, cooking, and cleaning the home. Staff said morning shifts were very busy and it was difficult to spend quality time with service users. A position for a domestic had been advertised. Staff said staffing levels had stayed the same even though two more service users had been admitted to the home. The manager said additional staffing hours had been agreed and from January 2007 an extra full time care staff would be employed and they would work on the days when staff had to transport service users to day services. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 22 Issues were raised by staff that the team had not been working as well together recently and not all staff were pulling in the same direction. There had been a higher than average level of sickness and some staff at the home had been working long hours to cover the shortfalls. This they said, had led to tensions amongst the team. Some of these issues had been discussed recently at a staff meeting and the minutes confirmed that the management team were aware of the issues and had taken steps to address some of the problems. A daily planner was being introduced that clarified staff responsibilities for each shift. The staff communication book also evidenced that there were staffing problems at the home. One person had written that staff were ‘winding up service users causing them to self harm or become aggressive towards others’ and another staff wrote ‘ staff were not pulling their weight’. Again there was evidence that the manager was looking into these issues. Staff meetings are held approximately every two months. The minutes confirmed various topics were discussed. 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 talked about the induction process and said they felt well supported and were in the process of completing the induction workbook. Recruitment records for two staff were looked at. All the relevant information was available but the employment history for both staff was not satisfactory. One application form did not have information about employment history and another form only had parts of the employment history. Training records were looked at and these confirmed that staff had attended a range of training courses. Some recent training had not been included on the training record and the staff responsible was in the process of updating this. The manager stated that six staff had completed NVQ level 2 or equivalent, which means over 50 of staff hold a care qualification. Staff have attended crisis prevention training, which teaches people how to deal and diffuse volatile situations, low level holds are also taught. Staff said the training gave them the skills and confidence to handle difficult situations. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 23 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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager takes steps to start putting things right when problems are identified and senior management also become involved. Health and safety checks are carried out regularly and generally environmental problems are dealt with promptly. EVIDENCE: The manager said she had completed five units of the Registered Manager’s Award and hopes to complete it in February 2007. The inspection highlighted certain areas where the home was not providing a satisfactory service. The manager was aware of many of the issues and had taken action to address some of the problems. Three service user meetings have been held in the last seven months. The minutes confirmed that service users were asked if they were happy with the Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 24 home and with the food, and they were asked for activity and holiday suggestions. The organisation had completed service user and relative surveys. One had recently been completed but the results were still being analysed. Once a month the provider visits the home and looks at the general conduct, these visits are called Regulation 26 visits. The area manager has visited the home and completed these visits. The reports were looked at during the inspection and they had sufficient detail to demonstrate that the provider is monitoring the quality of the home. Copies of reports from these visits should be sent to the CSCI but none have been received since December 2005. The area manager had attended a recent staff meeting to talk about issues. Regular checks are carried out around the building and these are recorded. The records confirmed that fire systems, emergency lighting, nurse call and general lighting were checked. This is good practice because health and safety problems have been identified as they arise and generally dealt with promptly. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 25 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 X 2 1 3 1 4 X 5 2 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 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 1 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X X 3 X Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. YA2 14 Standard Regulation Requirement New service users must only be admitted to the home on the basis of a full assessment undertaken by people competent to do so. The registered person must ensure the home is suitable to meet the assessed needs of service users that move in. Service users must be provided with details of the total fee payable in respect of the service they receive. The registered person must ensure service users’ rights are only limited through the assessment process. The registered person must ensure risks to service users are identified and so far as possible eliminated. This relates specifically to self-medication, assessment of risks identified at previous homes. The registered person must ensure recommendations to reduce risks are followed up. Health care needs must be properly monitored. DS0000001523.V321095.R01.S.doc Timescale for action 28/02/07 2. YA3 12 28/02/07 3. YA5 5 28/02/07 4. YA7 12 28/02/07 5. YA9 13 28/02/07 6. YA19 12 28/02/07 Woodhouse Hall Version 5.2 Page 27 7. YA20 13 8. YA23 13 9. YA24 13 10. YA24 23 11. YA30 16 Care plans must contain information that consents to care workers administering medication and personal preference for administration. The registered person must ensure events that relate to the health and welfare of service users are recorded. This includes any incidents when restraint/ low level holds have been used. The registered person must make sure all areas of the home to which service users have access are free from hazards to their safety. This relates specifically to the water temperatures in the bathrooms. The registered person must make sure equipment is maintained in good working order. This relates specifically to the extractor fans in the ground floor bathroom. The registered person must make sure the home is free from offensive odours. The flooring in the bathrooms must be impermeable to enable proper cleaning to take place. The registered person must ensure staff respect service users and have the competencies and attitudes required to meet service users’ needs. The registered person must ensure there are sufficient staff on duty to meet the needs of the service users. The registered person must ensure a full employment history has been obtained for all persons employed at the home. The registered manager must complete a relevant management relevant qualification. DS0000001523.V321095.R01.S.doc 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 13 12. YA32 18 28/02/07 13. YA33 18 28/02/07 14. YA34 17 28/02/07 15. YA37 9 30/04/07 Woodhouse Hall Version 5.2 Page 28 16. RQN 26 The registered person must ensure copies of Regulation 26 visit reports are sent to the CSCI 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA13 YA16 Good Practice Recommendations The registered person should remove information from care files that is no longer relevant. Service users should have more opportunities to go into the community. Documents that the home devises for service users to sign should be written in plain English. Woodhouse Hall DS0000001523.V321095.R01.S.doc Version 5.2 Page 29 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.V321095.R01.S.doc Version 5.2 Page 30 - 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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