Inspection on 11/12/06 for Woodland View

This inspection was carried out on 11th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodland View 12/10/05

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

CARE HOME ADULTS 18-65 Woodland View Sea View Ryhope Sunderland SR2 0GW Lead Inspector Gillian McCabe Unannounced Inspection 11 , 12 & 19 December 2006 09:30 th th th Woodland View DS0000063668.V319268.R02.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 Woodland View DS0000063668.V319268.R02.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. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodland View Address Sea View Ryhope Sunderland SR2 0GW 0191 5214497 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) South of Tyne & Wearside Mental Health NHS Trust Helen Patricia Crisp Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (1) of places Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 2005 Brief Description of the Service: Woodland View is a six bed roomed purpose built bungalow providing personal care for young adults with learning disabilities. The Home does not provide nursing care. The Home is on the outskirts of Ryhope, set in it’s own spacious and private area with a security gate at the entrance, operated by staff in the Home. It has ample car parking and is surrounded by landscaped gardens and has a patio area to the rear of the property. The Home provides it’s own minibus for access to local community services, as the Home is not situated near amenities. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was carried out over two days in December 2006 and was part of a scheduled unannounced inspection. The service inspection also included a separate look at the pre-inspection questionnaire (completed by the manager) and three comment cards received from residents and/or their relatives. The manager was not available during the site visit however; a telephone conversation was carried out after the site visit to gather the manager views. A tour of the building took place, and a sample of residents and staffing records were looked at. A sample audit of the homes system for receiving, storing, administering and disposing of medication also took place. Time was spent talking with residents throughout the site visit and meeting two visiting relatives. Time was also spent talking with the homes deputy manager and members of staff working at the home. The judgements made in the report are based on the evidence available to the inspector during the site visit and the pre-inspection questionnaire completed by the manager. What the service does well: Staff in the home encourage and promote residents to access local community services and facilities. Good relationships between staff and residents are clear and key workers have a very good knowledge of residents’ likes and dislikes. Good communication passports have been developed for some residents. Residents are encouraged and supported to keep in touch with family and friends and members of staff encourage friends and family to visit the home at any time throughout the day. Comments from relatives about the service include ‘We are much happier that xxxxx is living here. We can visit more regularly as Woodland View is much closer. The care is excellent and xxxxx seems to be a lot happier’ ‘We are always made to feel welcome when we visit, and we can help ourselves to a cup of tea’. ‘ XXXX has never been so happy and contented since he went into Woodland View. They love him to bits, and it shows in the way they all care for him, it makes us really happy’. ‘We are more than satisfied with the care provided’. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It is important that all residents’ contracts are completed with all the necessary information and signed by relevant people. Residents support plans and risk assessments are reviewed on a regular basis. However, some outcomes are written in the same context, for example ‘no change’ ‘ongoing’ this kind of wording does not tell the reader how or if a person is progressing with a particular area. Minutes for residents meetings are in written format and would benefit from being produced in pictorial format or a format that is easily understood by all residents. Storage space should be found for items stored in the homes activities room, this would enable this room to be used for each planned activity. For residents that need to have fluid intake monitored, it is important that the quantity of fluids taken are recorded. All stock of medicines received into the home must be recorded on medication records. Anti topple device should be fitted to freestanding wardrobes. Quality systems should be in place to measure all areas of the service. The home does not always notify Commission for Social Care Inspection of any incidents or accidents under Regulation 37. Time was spent talking with a senior member of the team about the type of incidents/accidents that need to be reported to Commission for Social Care Inspection Woodland View DS0000063668.V319268.R02.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. Woodland View DS0000063668.V319268.R02.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 Woodland View DS0000063668.V319268.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents needs have been assessed prior to their admission and good assessments are in place identifying individual needs, wishes and aspirations. Residents are provided with a written/pictorial statement of terms and conditions/contract before admission into the home. It gives adequate information on what people who live in the home can expect to receive for the fee they pay. EVIDENCE: The service has an admission procedure in place outlining the process prior to admission. Admissions to the service only take place if the service is confident it can meet the needs of the prospective resident. Comprehensive and Full needs assessments are carried out prior to admission into the service. This information makes sure staff know how to support and assist each person correctly. Prior to moving into the home residents are given he opportunity to visit, have a meal and stay overnight if they wish before a decision is made about coming to live at the home. Woodland View has service user contracts in place giving details of the homes terms and conditions regarding occupancy. The contract is produced in written and pictorial format making it a little easier for residents to understand. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 10 Details of fees payable by residents are not clearly shown on individual contracts and residents or their representative have not always signed each contract to say they agree with the terms and conditions of the home. One member of staff confirmed that advocacy had previously been involved and staff are exploring the possibility of family member/s acting as a representative for people that may be unable to sign independently. Woodland View DS0000063668.V319268.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents assessed needs are reflected in their individual support plans, which provide guidance for staff to ensure residents’ needs are met. However plans would benefit from being developed in a more person centred way. Residents are consulted on and participate as much as possible in the running of the home. This helps to promote independence and inclusion. Residents are supported to take some risks within a planned framework as part of an independent lifestyle. EVIDENCE: Good support plans are in place giving details of individual needs and support on a daily basis. One person already has good person centred plans in place that include comprehensive details about individual aspirations the person wants to achieve. Staff have supported this person to achieve nearly all of the goals identified, which is excellent. Plans are in place to develop person Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 12 centred support plans for all residents to ensure aspirations are achieved and support is given as requested by each resident. Plans are evaluated regularly to reflect any change in needs or aspirations. The service has also recently developed communication passports for one resident and is in the process of developing communication passports for all residents. Each passport provides information about individual communication needs and how a person may need support with particular areas of care for example, how a person prefers to communicate, how a person may need help with eating and drinking, what type of equipment a person may need. All residents have key workers who encourage residents to participate in daily tasks such as tidying bedrooms, as part of promoting an independent lifestyle. Part of one residents support plan involves object referencing. This is carried out by using music and materials at certain times of the day, and in certain areas of the home. This helps to promote orientation and familiarity throughout the home. Residents meetings are held in the home and usually planned each month where discussions and plans are made for future events such as birthday parties, planning nights out to theatre, shopping trips and activities. Minutes are produced in written format and would benefit from being produced in pictorial format or a format that is easily understood by all residents. Generic risk assessments are in place for some areas of risk, for example, use of wheelchairs, using the toilet. Risk assessments may be reactive to situations that arise in the home and to keep people safe. Evidence of review of risk assessments is clear however, some outcomes of review would benefit from being recorded more descriptively. Some evaluations were written in the same context. For example, ‘no change’ or ‘ongoing’. These kinds of words do not tell the reader how a person is progressing with a particular area. It was clear however, from observations and discussion with staff that appropriate interventions are carried out. Woodland View DS0000063668.V319268.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and assisted to lead active and fulfilling lifestyles by having regular community presence and accessing a range of community facilities. Routines in the home are resident focussed, and changed to meet individual needs when necessary. Residents are supported to maintain contacts with friends and family both inside and outside the home. Meals provided are healthy, varied and attractively presented in a relaxed and unrushed manner. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 14 EVIDENCE: The home has an activities plan in place which is planned on a weekly basis involving residents as much as possible. A Key worker system is in place at Woodland View, which helps staff to establish good relationships with residents and work on a one to one basis. Key workers have a very good knowledge of what residents like to do each day and incorporate this into activity plans. Some residents like to get involved with cooking sessions in the home and some residents like to go swimming at the local swimming baths. Staff confirmed that residents are supported to access community facilities such as Winter Gardens, theatre, shops and local restaurants/public houses. During the site visit, staff and residents were preparing to go to their local pub for their Christmas night out. Woodland View has the benefit of its own accessible transport, which also helps to get people out and about. Staff confirmed that residents also like to get involved in weekly shopping which is carried out at local supermarkets. Residents are encouraged to keep in touch with friends and family members. Staff at Woodland View encourage friends and family members to visit the home at any time throughout the day, and residents may entertain their guests in the privacy of their own rooms, or in the communal areas of the home. Two visiting relatives spoken with during the site visit talked about how happy they were with the care provided for their son. Their comments about the service include ‘We are much happier that xxxxx is living here. We can visit more regularly as Woodland View is much closer. The care is excellent and xxxxx seems to be a lot happier’ ‘We are always made to feel welcome when we visit, and we can help ourselves to a cup of tea’. Comments from relative comment cards sent to Commission for Social Care Inspection are very positive. Comments include ‘ XXXX has never been so happy and contented since he went into Woodland View. They love him to bits and it shows in the way they all care for him, it makes us really happy’. ‘We are more than satisfied with the care provided’. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 15 Woodland View has the benefit of an activities room for residents to access on a daily basis. However, various items and equipment are currently being stored in the room, which makes it difficult for residents to access. Staff confirmed that activities such as arts and crafts, computer skills and picture bingo are carried out. Mealtimes in the home are at various times throughout the day. Breakfast is usually between 7.30am – 10.00am, Lunch is usually between 12.00pm – 2.00pm and evening meal is between 5.00pm – 7.00pm evening meal. Some residents have special dietary needs, staff have regular contact with the dietician to make sure residents needs are met in this area. Comprehensive records are available for monitoring food intake along with individual feeding guidelines. Some residents have difficulty in swallowing foods and also need support to eat a soft diet. Lunch was taken with residents, the experience was relaxed and unrushed and residents were supported to have their meal at their own pace. For residents who need support during mealtimes, staff gave assistance in a discrete and sensitive manner. The service has written menus in place, which residents may have difficulty in understanding. Menus do not show a choice of meals however, alternatives are available if residents indicate they dislike what is provided. Residents have difficulty expressing themselves verbally and would find it difficult to indicate what they would like from homes menus. Key workers rely on the knowledge they have, of individual residents likes and dislikes to determine what residents may or may not like when planning the homes menu. Examples of meals on the menu include sausage in gravy and mashed potatoes, roast pork and apple with roast potatoes, turnip, cauliflower and brussel sprouts. Deserts include chocolate cake and white sauce, mousse, fruit, apple crumble and custard. Woodland View DS0000063668.V319268.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health care needs are identified in individual support plans and arrangements are in place to ensure health care needs are promoted and met. Good medication arrangements are in place and managed well which promotes the health and well being of residents. EVIDENCE: Health action plans are in place in written and pictorial format giving details of residents’ health related needs. These plans give details of any medical conditions a person may have and how they need to be supported. The plans also give details about any specialist equipment or health related need where a person may support. One member of staff spoken with confirmed that close contact is maintained with relevant healthcare professionals when necessary, staff support residents with attending to healthcare needs and actively seek advice from health care professionals where necessary. This ensures residents physical and emotional wellbeing is well monitored. Regular appointments are seen as important and Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 17 there are systems in place to make sure residents appointments are not missed. Records show that appointments and check ups have been made with relevant medical professionals such as Chiropodists, Dentist, Optician, Psychologist and G.P. Fluid and food monitoring charts are kept for residents each day however, it is sometimes not clear how much fluid a person may have taken in one day. For example, 2 cups of coffee are recorded as being given but not the quantity of fluids. This information is important for residents who need to have fluids monitored to ensure the correct quantity of fluids are given and the person does not become dehydrated. Medicines in the home are stored in a locked cupboard with the key being held by a senior member of staff. All staff responsible for handling medicines have completed training in Safe Handling Of Medicines, which means all staff have the skills needed to be fully competent in handling medicines. The manager and assistant manager are responsible for ordering any medicines in the home. Records looked at were up to date and signed appropriately however; some records, for liquid medicines did not have the quantities of stock recorded on the medication records. This information is important for the purpose of auditing. Staff confirmed weekly audits are carried out to ensure no mistakes have been made however; records were not available to look at during the site visit. Information is available for all staff to access to inform about various medications that is used in the home, along with details of any side effects that may occur as a result of taking such medicines. Woodland View DS0000063668.V319268.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a good range of information about how to make a complaint. Policies and procedures are in place to ensure staff have the knowledge and skills to protect residents from harm. EVIDENCE: The home has robust complaints policy and procedure in place in various formats, which include digital video disc (DVD), audio format, and written and pictorial format. Staff confirmed that the complaints procedure is explained to residents and their relatives upon admission into the home. Residents are also supported to access advocacy services when necessary. No complaints have been received into the home. Woodland View has a policy and procedure in place, which set out the values, and principles that underpin the homes approach to the protection of residents. This ensures that all residents are protected from harm. All staff have completed training around protection of vulnerable adult procedures. This training is important as it helps members of staff to keep up to date with the protection of vulnerable adult procedures. Staff are aware of whom to contact in the event of an alert. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 19 Discussion with the homes assistant manager, after the site visit, confirmed that members of staff have regular refresher training in this area. Guidelines are displayed in the office for all staff to access and familiarise themselves with when necessary. Woodland View DS0000063668.V319268.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and warm environment, which is generally well maintained. EVIDENCE: The home is nicely decorated and has a warm atmosphere. The property is kept clean and free from any odours. There are some signs of wear and tear in the home particularly near the doorframes and around some of the walls. Staff confirmed this is due to the use of equipment in the home and due to some of the door openings being too small. A maintenance plan for the home has not been developed yet as the building is fairly new however, there has been some minor faults which have been reported to Three Rivers Housing for attention. A conversation via the telephone was held with the assistant manager after the site visit about developing a maintenance plan for the home in the future. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 21 All residents have their own bedrooms, which are personalised to suit individual taste. Overhead hoists are fitted in all residents’ bedrooms to support with safe transfers. There are good-sized toilets and bathrooms in the home with specialist equipment to support residents when using the facilities. The home has a spacious dining room and a smaller sized lounge. Communal areas are nicely decorated and residents and visitors enjoy using these areas. Laundry facilities are provided in the home and are adequate to meet residents’ needs. During the site visit the laundry door was wedged open. Anti topple devices are not fitted to freestanding wardrobes in the home. Storage space needs to be found for items stored in the activities room, this will enable residents to use the room freely. The home has the benefit of extensive and well-kept gardens to the rear, side and front of the property. Access to the garden can be gained from the patio doors off the dining room or by the front or back doors of the property. The gardens also have the benefit of patio furniture, which is used in warmer weather. Woodland View DS0000063668.V319268.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a good recruitment procedure that clearly defines the process to be followed. Employment checks required for all employees could not be carried out as some records are held centrally. The service recognises the importance of training and delivers where possible a programme that meets statutory requirements. EVIDENCE: The service has a recruitment procedure in place that highlights the process to be followed. Staff records are held centrally therefore it was not possible to check if correct employment checks had been carried out prior to any new staff being recruited. Prior arrangements would need to be made with the trust to gain access to staff records. However, the assistant manager did confirm that all staff has had Criminal Record Bureau clearance prior to commencement of employment. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 23 The manager ensures any new members of staff within the service receive induction training, which covers all mandatory training. However, records looked at during the site visit were not complete. Staff spoken with talked positively about the training they receive programme and the support they receive in their role. Staff spoken with demonstrated confidence in their roles and a good knowledge and understanding of residents needs. Up to date staff training matrix was not available to look at during the site visit however, some training files were looked at and the assistant manager confirmed that all staff had completed mandatory training. The pre inspection questionnaire indicates that some members of staff have completed training in Epilepsy, Intensive Interaction, Equality and Diversity, Pressure Care, Care Planning and 44 of staff have completed an National Vocational Qualification (NVQ) Level Two and some have completed a National Vocational Qualification Level Three. The assistant manager confirmed that staff are regularly provided with training opportunities to help them better understand the needs of residents at Woodland View. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a well run home. The management team are approachable and available for residents and staff so that people living and working in the home are able to feel relaxed about how the home is run. The service does not have quality assurance systems for gathering and reviewing feedback from residents and/or their representatives about the services provided. The home has procedures in place for monitoring health and safety which are generally carried out. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 25 EVIDENCE: The current manager has been in post since the home opened and has the required qualifications and experience to run the home and meet its stated aims and objectives. Staff and relatives confirmed that the manager of the home is very approachable and supportive. Staff commented that they enjoy working in the home. The manager confirmed that health & safety checks are carried out as part of the homes quality assurance system, however water temperatures in the low level sink were measured and were reading at 55.9 which is too high. An immediate requirement notice was given for the temperature to be made safe. The assistant manager confirmed the following day that the water had been turned off at this sink and the relevant part had been ordered to regulate the water temperature. A telephone conversation with the assistant manager confirmed that quality assurance systems are not place for all areas of the service. The manager and assistant manager are planning to develop some questionnaires for residents and their relatives to measure quality in the home. This information will help to identify areas of poor and good practice. The home has external agencies that carry our checks periodically on the building and things like emergency lighting and fire extinguishers. This ensures that the environment and pieces of equipment remain safe and intact. Fire records kept in the home are up to date and any accidents/incidents that had occurred in the home are recorded appropriately. As part of quality monitoring the service also receives monthly monitoring visits. Checks are made on various aspects of the service and a monthly report is produced with the outcomes. Reports of these checks are not always forwarded to Commission for Social Care Inspection under regulation 26 of Care Home Regulations. The home does not always notify Commission for Social Care Inspection of any incidents or accidents under Regulation 37. Time was spent talking with a senior member of the team about the type of incidents/accidents that need to be reported to Commission for Social Care Inspection. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 26 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 3 3 X 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 27 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 YA1 Regulation 17(2) Schedule 4 Requirement Timescale for action 28/02/07 2. YA19 3. 4. YA19 YA24 Residents’ contract/statement of terms and conditions must show fees payable and must be signed by resident or their representative. 13(2) Stock of all medicines received into the home must be recorded onto individual medication records. 17(1)(a)Schedule Fluid charts must show 3 3 (m) amount of fluid that has been taken. 23(h)(l) Suitable storage facilities must be found for items currently stored in the homes activities room 24(1)(a)(b) 31/12/06 31/12/06 31/01/07 5. YA24 6. YA37 37(1)( c)(d)(e) Schedule 4 17(2) The home must have a 31/01/07 planned maintenance and renewal programme for the fabric and decoration of the premises, with records kept. The registered person must 31/12/06 notify Commission for Social Care Inspection of any incidents/accidents as discussed during site visit. Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 28 7. YA39 24(1)(a)(b) 8. YA39 26(5)(a) The registered person shall establish and maintain a system for reviewing and improving the quality of care provided at the home. Regulation 26 reports must be forwarded to Commission for Social Care Inspection on a monthly basis. 28/02/07 31/01/07 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. Refer to Standard YA6 Good Practice Recommendations Following support plan/risk assessment reviews where ‘no change in a residents needs have been found and plans have remained the same, information should be recorded to evidence staff judgements. A four-week menu should be considered to demonstrate a varied diet with details of a choice of meals for each mealtime. Consideration should be given for menus to be produced in pictorial or other accessible formats. 2. YA17 Woodland View DS0000063668.V319268.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South of Tyne Area Office St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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