Inspection on 27/04/05 for Woodhouse Road Care Home

This inspection was carried out on 27th April 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Woodhouse Road Care Home 09/10/09

Woodhouse Road Care Home 10/10/07

Woodhouse Road Care Home 26/07/06

Woodhouse Road Care Home 20/10/05

Woodhouse Road Care Home 03/12/04

Woodhouse Road Care Home 26/05/04

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Jubilee Villa Care Home

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Beech Lodge

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Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Woodhouse Road Care Home 31 Woodhouse Road Mansfield Nottingham NG18 2AY Lead Inspector Meryl Bailey Unannounced 27 April 2005, 10:00 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 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 Stationary 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 Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodhouse Road Care Home Address 31 Woodhouse Road Mansfield Nottingham NG18 2Ay 01623 651398 01623 651398 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Mencap Society Audrey Baranski Care home 8 Category(ies) of Learning Disability (LD), x 8 registration, with number of places Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No more than 8 Service Users with Learning Disabilities to be admitted. Date of last inspection 03/12/04 Brief Description of the Service: 31 Woodhouse Road provides long-term personal care and accommodation for 8 adults who have a learning disability. Two service users over the age of 65 years. The home is located near Mansfield town centre and is close to shops, pubs, the post office and other amenities. The premises consist of a large end of terrace house. Bedrooms are single with no en-suite facilities and are located on the second and third floors. There is a good-sized enclosed garden that is easily accessible. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and conducted by one inspector during one afternoon. Five of the current seven service users were at home and four staff were seen during two shifts, but the manager was not present. There was one current vacancy. Some service users and staff gave their views about the care provided, but no visitors were present on the day of this inspection. The communal areas of the home were inspected and a sample of bedrooms was also seen. What the service does well: 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. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 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 standard(s) 1 and 2 Full, clear up to date information about the service is not available. Current service users have been admitted following full assessments of their needs. EVIDENCE: Staff reported that the Statement of Purpose and Service User Guide have been updated to contain all required information, but these documents are with another manager within Mencap and not currently available within the home. None of the service users have an updated Guide. The files of three service users were examined and contained pre admission assessments and further assessment material though not all care plans were present. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6 and 7 Individual plans reflect assessed needs, though they are not in place for all service users. The omission of a plan and the lack of regular reviewing for those over 65 years may result in some needs being neglected. EVIDENCE: Two of the three service users’ files inspected contained clear care plans for various aspects of care and support. There was evidence of the service users being involved with care planning with the use of “Listen to Me” workbooks. There was no plan on file for a service user admitted in December 2004. Staff reported that the key worker was compiling one. There was no monthly reviewing of the care plans for service users over the age of 65 years. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12, 14,15 and 16 Service users choose a wide range of daily activities. Staff work to support service users making individual choices and the daily routines are designed to promote this. EVIDENCE: Service users have opportunities to attend local day centres, local colleges and a craft centre. Local facilities like the cinema, leisure centre and pubs are also accessed. Within the home service users were observed watching television, listening to music and one was in the greenhouse. Other activities were available within the home aswell as books and a computer. Seven service users and four staff are going on a holiday in May and have been involved in the planning of this. The visitors’ book showed regular visits from friends and family. All service users are given their own key to their room and these were seen in use. All, but one, service users have a key to the main doors. Minutes were available of regular house meetings where service users are able to raise any matter they wish for discussion. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 11 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 standard(s) 18, 19 and 20 The model of care planning in place enables service users to receive the personal support in the way they prefer. Medication is well organised and staff are all trained in handling and administering medication. EVIDENCE: Two of the three care plans seen were comprehensive in detailing the support preferred and required. Full information was recorded on files regarding medical appointments and advice received. A service user was accompanied by staff to a dental appointment on the day of this inspection. Daily notes were up to date, and staff were observed completing these before going off duty. Medication was seen and found to be appropriately and securely stored. Staff reported having had training in the administering of medication from Boots in addition to induction training and medication was also covered in the First Aid course. Medication records were well maintained. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 12 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 standard(s) 22 and 23 Service users are made aware of how to complain and are protected from abuse. EVIDENCE: The complaints procedure is displayed on a notice board in written and picture format. There is a book in place to record complaints in and any action taken. No recent complaints have been received and recorded. Two service users said that staff had told them about the complaints procedure. The training programme for staff includes awareness of adult protection and whistle blowing policies with “Protect me from Abuse”. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 13 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 standard(s) 24, 26, 27, 28, 29 and 30 The home is well suited to its purpose provided service users do not have any mobility needs. Shared spaces are comfortable and individual rooms reflect individual preferences. There are some external maintenance needs. EVIDENCE: The lounge, dining room and conservatory give service users a choice of shared spaces and these were found clean, comfortable, and well maintained. The garden is untidy and work is needed to develop the outside area. There is no access to the rear via the conservatory, but a rear exit is provided via the kitchen. The unsafe ramp, reported after previous inspections, had not yet been removed, but work was due to commence on the day following this inspection. Current service users are able to use steps, but staff reported that one service user struggles to her room on the top floor. All bedrooms are on the upper two floors and no lift is provided. Four of the bedrooms were seen and were found clean, individual and service users present said they had everything they needed. A tree has been cut back to allow more light into two of the rooms, but still blocks light to one bedroom with a small window. Bathrooms and toilets are appropriately sited meet needs. The openings of “Velux” windows, though, need to be restricted for safety (see Standard 42). Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 Service users are supported by trained staff and generally protected by recruitment practices. EVIDENCE: The staffing rota shows that there are always at least two staff on duty to support service users. Mencap’s recruitment policy and practices are followed, however there was no completed Criminal Record Bureau check for one staff member on duty. He reported having completed three application forms for the check to be processed but these forms may have been mislaid. Appropriate references have been obtained. Staff on duty were observed interacting well with service users and were extremely patient and understanding expressive communication. Service users said they liked staff and felt that they were well supported. Training listed as completed by staff members present included: Manual Handling, Food Hygiene, Personal Safety, First Aid, Risk Management, Down Syndrome and Dementia Awareness, and Epilepsy Awareness. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 and 42 The management approach benefits the service. Health and safety within the environment are generally promoted, but further steps should be taken to ensure all areas are safe. EVIDENCE: The registered manager was not present during this inspection, but is, reportedly, currently undertaking the registered managers award. Staff report that the service has benefited from the strong leadership of the manager during the past year. Staff have regular structured staff meetings, with minutes available for inspection. Staff are trained in safe working practices. The fire log was up to date and there is an external fire escape from each floor. The fire doors are alarmed. There are safety notices in the kitchen with appropriate pictures to support the written words. Openings of windows have been restricted for safety and security with the exception of the “Velux” windows on the second floor. The external area should be tidied and made safe including the uneven drive. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 3 2 3 Standard No 11 12 13 14 15 16 17 x 3 x 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodhouse Road Care Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 2 x C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 17 Yes Are there any outstanding requirements from the last inspection? 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 YA 1 Regulation 6 Requirement Provide a copy of the updated Statement of Purpose and Service User Guide to the Commission. Provide a copy of the updated Service User Guide to each service user Ensure an individual care and support plan is in place for all service users. Remove the ramp to rear of the building. Previous target date of 1st April 2005 was not met Ensure the outcomes Criminal Record Bureau checks are received for all staff prior to employment. Timescale for action 30th June 2005 30th June 2005 31st May 2005 31st May 2005 30th April 2005 2. 3. 4. 5. YA 1 YA 6 YA 24 YA 34 6 15 23 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA 6 YA 24 Good Practice Recommendations Review the care plans of those over 65 years at least every month. Tidy and develop the external areas to provide a safe driveway and rear garden for service users. C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 18 Woodhouse Road Care Home 3. 4. YA 29 YA 42 Reassess the mobility needs of the service user who struggles to her room on the top floor and meet these appropriately. Restrict the openings of the Velux windows on the second floor to 100mm as recommended by police. Woodhouse Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Road Care Home C53 C03 S8769 Woodhouse Road V223762 270405 Stage 4.doc Version 1.30 Page 20 - 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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