Inspection on 14/01/08 for Woodlands

This inspection was carried out on 14th January 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Woodlands 435 Shirley Road Acocks Green Birmingham B27 7NX Lead Inspector Philip Farmer Unannounced Inspection 14th January 2008 09:30 Woodlands DS0000070489.V357439.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 Woodlands DS0000070489.V357439.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. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Address 435 Shirley Road Acocks Green Birmingham B27 7NX 0121 778 5718 0121 778 5718 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) suehullin@tracscare.co.uk Tracscare Group Ltd Andrew Simon Ogden Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category PC Care Home Only to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Mental Disorder MD 6 The maximum number of service users to be accommodated is 6. Date of last inspection First Inspection Brief Description of the Service: Woodlands Care Home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of six adults with a mental Health issues. Woodlands is located in the Acocks Green area of Birmingham its is close to: Bus and Rail links A public Leisure Centre Park There are several shopping areas within walking distance. The house is a large detached property of brick and tile construction; it is set out over three floors. It has been refurbished to a high standard. The accommodation consists of six single occupancy bedrooms all with en-suite facilities, which include a walk in shower. Two bedrooms are on the second floor, three on the first floor, and one ground floor bedroom. There are two lounges one is used as quiet room, the larger lounge has a raised covered patio area accessed via double glazed doors, and it is used as a smoking area. There is kitchen that is conducive to the size of the home and number of people to be accommodated. This includes an adequate dinning area for up to Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 5 eight people. There is Private external recreational space is provided to the side, rear, and front of the property, it has it’s on private drive offering parking for three to four cars. The registered provider is TRACS Ltd. Ms Susan Hullin is the responsible individual and Simon Ogden is the registered manager of the service. Fees charged per person range from £1800.00 per week. Information about this service is available from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection was unannounced and took place on 14th January 2008 undertaken by one inspector over three and half hours. A range of evidence was used to make judgements about this service. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults. A quality rating is provided throughout the report based on each outcome area for the people who use the service. An Annual Quality Assurance Assessment (AQAA) had been completed by the manager and submitted to CSCI prior to this inspection, offering a full overview of the home. Four people currently live at the home and during the inspection were observed to be accessing all areas of the home. The registered manager was on the premises supported by four care staff. Care provided for two people at the home were examined in detail, relevant documents were inspected, discussions were held with people living at the home, staff, and the manager. Observation was made of the various daily activities and a tour of the premises was conducted. As this is the first key inspection of this service following registration and the home has been operating since September 2007 a rating of “excellent” cannot be given as it is considered that the service needs to demonstrate this level of performance over more time. However, many of the outcomes for service users are very good and there seems no reason, given the systems and the enthusiastic approach of the manager and owner, that this level of performance will not be achieved. What the service does well: Woodlands is well presented home to both prospective clients and people who live there both in general appearance and in the excellent sources of information provided to enable prospective service users to decide if the home will suit them. Arrangements for pre-admission visits and trial periods are seen by service users and staff as very helpful to settling in to the home. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 7 The home has very good assessment procedures and care planning systems in place and service users are confident that their personal needs are understood and can be met. The plans are devised to assist the service users to have a full and active life and the one to one staff provision supports this. One relative said, “ the staff at the home make my relatives stay there as comfortable as possible. They do all they can to accommodate.” Staff are seen to have excellent relationships with the residents, interacting naturally, with understanding and delivering care as the person wishes, achieving a high level of satisfaction and sense of well being amongst the residents. Residents take part in making choices about their meals. A number of staff returned comment forms and were spoken to on the day, all thought the service was a good one providing a well run service to the people who live there. The home makes sure that residents get routine and specialist health care. One health care professional said “ Woodlands staff, help our service users to a more adaptive lifestyle.” The home is spacious and well decorated and kept clean and fresh. Each person who lives at the Woodlands has their own bedroom and bathroom and these show the personality of the individual that lives in it and are used by residents throughout the day as they please. Staff are recruited and selected in ways that ensure safe skilled individuals are employed and the home demonstrates a good commitment to staff training. What has improved since the last inspection? What they could do better: It is considered that this agency is currently performing very well, setting its own objectives for continual improvement. No requirements inspection. or recommendations have been made following this The service has identified a number of area’s that it will seek to improve, they already involve people who live at the Woodlands in there own care planning, general rights and responsibilities, Quality and involvement in meetings. They will continue to improve the quality and frequency of activities by actively involving the participants in choices they make. Through relationships with Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 8 local college’s, improve links. They will continue to improve induction as they see this as key to the retention of good quality staff. External quality audits will continue to raise standards at Woodlands. 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. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 9 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 Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 & 5 Quality in this outcome area is good. People who live at Woodlands are provided with the information needed to decide whether this service will meet their needs. They have their needs assessed prior to admission and a contract, which clearly tells them about the service they will receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection, there were four people living at the home they had all come to live at the home during the past three months, since the homes registration in September 2007. The home has a Statement of Purpose in place, which had been reviewed in line with the companies quality policies. The Manager stated a further review is being made to make the Service User Guide more accessible. The care records belonging to two people who have been admitted to the home since the last inspection were looked at. The assessment process is detailed it covers all area’s, a care plan is developed Prior admission a formal review takes place involving all parties 13 weeks after a person moves into the home and at six-month intervals. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 11 Assessments of need undertaken by the organisation were available on both files examined and were very detailed involving the individual, professionals and family. Other reports to support assessments were available for example an independent social circumstances report. Detailed service level agreements were available on files examined signed and dated by the service user and manager. Discussions held with the manager show that referrals to the service are given serious consideration to ensure that detailed information about the person is obtained, compatibility with others considered and that staff have the necessary skills to appropriately support an individual prior to a service being offered. The Manager stated that they have developed care-planning training for staff this includes specific clinical assessments that feed into the care plan. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 12 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 excellent. Staff are provided with detailed information to ensure service users’ assessed needs are met. The people who use the service are supported to make decisions and are enabled to take responsible risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The support plans for two were examined for two people the plans were detailed covering all aspects of the person’s individual needs with evidence of regular review. Reactive management plans were comprehensive as required by the previous inspection. Discussions held with the two people found that they were involved in planning their care and had signed their plans with the manager. Minutes of individual planning meetings were available in addition to an agenda and invitations to important people for forthcoming meetings. Records seen demonstrate that people are very much involved in planning for their meetings. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 13 Discussions with people who use the service indicate they are actively consulted on how the service runs and regular client meetings are held with people setting their agenda to include day-to-day life, menus, activities, staff appointments, and the development of the service. Staff are well aware of risk assessments and the need to adhere to them to minimise risks arising from identified hazards. A range of appropriate risk assessments is in place for the service users whose care was looked at in detail. This effectively demonstrated that service users are respected and offered choices. Activities are evaluated. Information provided indicated that care planning has been developed by Tracs this includes a review sheet that allows a more detailed comparison against the support strategy. The manager stated that they will continue to review all processes in relation to care planning and review to ensure people who live at the home are fully involved. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 14 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): 12,13,15,16 & 17 Quality in this outcome area is good. People who use the service are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We spoke to two people who live at the home one stated that he had been supported by staff to look for suitable employment this included new life opportunities and develop their skills coordinated with their designated key worker. Life skills assessments are undertaken and these were available on the files examined. Both people spoken to are been supported with a view independent living over the next year. People living at Woodlands are encouraged to develop and maintain relationships with family and friends and all contact is recorded. One person Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 15 said that he regularly visits a family member and links with the home are well established. Another person said that his Girl friend is a regular visitor to the house. Another was supported by the home to arrange an anniversary meal for him and his long-term girl friend. One person had expressed concerns about his ability to attend external further education due to confidence with some practical skills, the staff arranged for a tutor to come to the Woodlands to provide this support. People spoke about their rights being promoted and that they are treated with respect. A staff member was seen to knock on bedrooms doors during the inspection. Where there are limitations on choice or facilities, it is in the person’s best interest. Discussions held with two people evidenced that they understand and agree the limitations, which are fully documented and reviewed on a regular basis to ensure their ongoing relevance. Service users said that they are encouraged and supported with domestic tasks around the home and take responsibility for their own room, assist with menu planning, shopping and the cooking of meals. Activities are scored, by the participant to ascertain the level of satisfaction and if they wish to repeat it, this is included in the care plan. The Manager stated that he had arranged support for the spiritual needs of people who live at the home, all though they recognised it was difficult to maintain. The menu seen offered choice and records evidence that individuals are catered for. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. Service users are supported to maintain their personal care in accordance with their preferences and with attention to their privacy and dignity. Service users receive regular health screening and action is taken in response to identified changes in health. This helps service users to stay as healthy as possible and gives them the best opportunity to recover from any ill health. Some action is required to improve medication systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Support requirements were available on both files that we examined and people spoken with said they regularly access health appointments with support if required and outcomes recorded. Minutes evidenced that people from different organisations regularly attend meetings arranged by the home in the best interests of those accommodated. Medication procedures appeared satisfactory at the time of the inspection. Medication guidance along with a conversation the manager was able to demonstrate a clear understanding of his role and responsibilities in relation to Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 17 how this is managed. It was reported that three members of staff have undertaken accredited training via the distance-learning route. Records show that staff monitor and record any observed changes in a service users health and medical advice and treatment is obtained. There is evidence that issues are followed up with medics as records are well completed by staff with sufficient detail to evidence this. An audit of medication practices has been undertaken by the dispensing pharmacy with no concerns identified. The home has obtained a copy of guidance on Administration and Control of Medicines in Care Homes and this was seen readily available. All service users are assessed on their ability to self-administer their medication and their medication is regularly reviewed by the appropriate healthcare professional. One person reported that he would prefer to administer his evening medication in his own room for reasons of comfort, which the manager agreed to look into. The Manager stated that more staff would complete the medication training shortly. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. People who use the service and their representatives are able to express their concerns and have access to an effective complaints procedure. Appropriate procedures are in place to safeguard service users from potential abuse. There have been no incidents that have compromised their protection and they are considered to be safe This judgement has been made using available evidence including a visit to this service. EVIDENCE: One complaint has been received from a neighbour. Records showed that the Manager met with the neighbour and the matter was satisfactorily resolved within a day of receiving the complaint. There has been one complaint made to the commission. The complainant had also raised the issues with the home and this matter had been dealt with. The record relating to this matter was seen and the person who made the complaint confirmed a satisfactory outcome. The complaint procedure is strong and people who live at the home are aware of it a poster is also displayed on a notice board in a communal area. There have not been any incidents that compromise service users protection. The service has good protection procedures, which protect vulnerable people and protect staff. Recruitment procedures support this Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 19 Staff have received training in intervention techniques and refresher training as required. Financial policy and procedure for the management of service users monies is robust and safeguards both service users and staff. Financial handling assessments were available on the files examined. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 &30 Quality in this outcome area is excellent. The physical design and layout of the home enables people who use the service to live in a safe, well maintained, and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodlands was first registered in September 2007 the house is a large detached property set out over three floors. Tracs have refurbished the entire premises; furnishings are in accordance with relevant sections of the National Minimum Standards for younger adults and are of a high standard. The accommodation consists of six single occupancy bedrooms all with en-suite facilities, which include a walk in shower. Two bedrooms are on the second floor, three on the first floor, and one ground floor bedroom. All bedrooms all meet or exceed current NMS with regards to personal space. There are two lounges one is used as quiet room, the larger lounge has a raised patio area accessed via double doors, and it is used as a smoking area. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 21 There is a bathroom with shower and toilet on the first floor and separate toilet. A disabled person toilet is located off the smaller lounge. Appropriate kitchen and catering equipment is available that is conducive to the size of the home and number of people to be accommodated. This includes an adequate dinning area for up to eight people. A laundry room is provided on the ground floor with relevant domestic style equipment being provided. An office with adequate storage space for monies, medication is provided on the first floor. A sleeping in room is located on the second floor. Private external recreational space is provided to the side, rear, and front of the property, it has it’s on private drive offering parking for three to four cars. The heating system radiators within the home can be thermostatically controlled and are of a low surface temperature type. Managers and staff are satisfied that they have sufficient equipment to meet service users current needs and where needs change staff and Managers know which agency to approach to reassess the suitability of equipment. Bedrooms have been personalised to reflect the tastes and interests of the service users who occupy them. The home was found clean throughout during this unannounced inspection and responsibility concerning household tasks were seen on the files examined and people were observed assisting with tasks around the home during the inspection. Cleaning schedules are in place and personal protective equipment readily available. Products hazardous to health are appropriately stored and data sheets and assessments available. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 & 36 Quality in this outcome area is excellent. The people who use the service are supported by a trained, committed staff team and are safeguarded by the homes recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The team consists of ten staff and one manager. Discussions with the manager demonstrate that the provider has a good understanding of equality and diversity of the team, which reflects the gender of the people using the service. One support worker holds an NVQ level 3 qualification and a further four people are due to complete their award this month. A minimum of two staff are deployed on each shift to support the current people accommodated. One person stated ‘Sometimes current staffing levels limit things that we can do and we only have one driver here’. Another person stated ‘Staff are very good at their job, my key worker is very good and I get on well with him’. Staff spoken with considered staffing is sufficient and that the team are effective in meeting the individual needs of the people accommodated. Discussions with people using the service evidenced they have confidence in the staff and management team. They spoke very positively about the service provided and the relationships developed with the staff supporting them. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 23 Observations made evidence that the staff have the skills to communicate effectively with all service users. All staff are newly appointed three personnel files were randomly selected and examined and contained all the documentation as required by Schedule 2 of The Care Homes Regulations, as amended. Certificates to evidence training and qualifications are placed on individual files; those who use the service are involved in staff selection One member of staff stated ‘The organisation is excellent to work for and they provide us with good training opportunities’. He spoke about the training received over the last twelve months to include mandatory and service specific training and that training needs are identified through regular supervision and appraisal. The manager has developed an overall training matrix as advised following the last inspection and staff have individual training records. The manager stated that she intends to source training in ‘self harm’, which CSCI strongly supports following the number of notifications received since the last inspection in relation to one person. The staff member most recently appointed is currently undertaking accredited induction training over a twelve week period and his workbook was seen and his induction process discussed with him during the inspection. It is evident that the service sees induction and the probationary period as being an extension of recruitment. Staff meetings are held regularly and service users take it in turns to attend the meetings and detailed minutes are held. Evidence of staff supervision and appraisal was seen on files examined and confirmed in discussions with staff. Woodlands DS0000070489.V357439.R01.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): 37,39 and 42 Quality in this outcome area is good. The service is effectively managed, aspects of performance are reviewed, and the health and safety of service users and staff promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has the qualifications required of his role position and has attended various training courses. Discussions held with service users and staff in relation to how the service is managed strongly evidence that the ethos of the home is open and transparent. One person said ‘The manager is fantastic, he is fair and always helpful and here for you’. Another person stated ‘The manager is very good, I get on extremely well with him, he is approachable and supportive’. Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 25 Effective quality assurances systems are in place and the views of service users and their representatives are sought through staff and service user meetings. Monthly visits required by Regulation 26 are undertaken and comprehensive reports are held on site and a copy forwarded to CSCI. A quality audit of the service was very recently undertaken by the organisation and the home achieved 94 . The manager completed a form about the home and sent this information to CSCI, which identifies the strengths of the home and areas for improvement. Health and Safety procedures were good at the time of the inspection. Service certificates and health and safety files are well organised. All accidents are analysed by the organisation on a monthly basis and a report kept. Staff spoken with confirmed they are in receipt of training in safe working practices and shortfalls have been identified and training booked for example, manual handling. Risk assessments have been undertaken and are regularly reviewed. The manager committed to undertake a first aid risk assessment to meet new guidelines and arrange a fire drill to ensure all service users are familiar with the homes evacuation procedures in the event of a fire. Woodlands DS0000070489.V357439.R01.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 3 2 4 3 X 4 3 5 3 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 27 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 77 Paradise Circus Queensway Birmingham B1 2DT 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 Woodlands DS0000070489.V357439.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!